=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801942354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IDAHO ORTHOTIC PROSTHETIC SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2007
-----------------------------------------------------
Last Update Date | 06/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 425 S WHITLEY DR STE 431
-----------------------------------------------------
City | FRUITLAND
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83619-2611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-1294
-----------------------------------------------------
Fax | 208-884-1293
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8880 SW NIMBUS AVE STE A
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97008-7111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-765-5081
-----------------------------------------------------
Fax | 503-765-5081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACT SPECIALIST
-----------------------------------------------------
Name | DIANA K MORRISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-765-5081
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------