=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629089792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRONTIER ORTHOPEDIC SERVICES, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 04/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 E. CARLSON STREET SUITE 115
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82009-4311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-637-3131
-----------------------------------------------------
Fax | 307-637-4405
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 E. CARLSON STREET SUITE 115
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82009-4311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-637-3131
-----------------------------------------------------
Fax | 307-637-4405
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRACTITIONER
-----------------------------------------------------
Name | MR. JAMES FREDERICK JACKSON
-----------------------------------------------------
Credential | BOCP
-----------------------------------------------------
Telephone | 307-637-3131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | C12686
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------