=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790381994
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRIDE PROSTHETICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2020
-----------------------------------------------------
Last Update Date | 12/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 N MAIN ST STE 110
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81003-3257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-581-7399
-----------------------------------------------------
Fax | 888-508-6271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 611
-----------------------------------------------------
City | FLATWOODS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41139-0611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NICHOLAS WHEELER
-----------------------------------------------------
Credential | BOCP, LP
-----------------------------------------------------
Telephone | 606-585-4996
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------