=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861997322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL COLORADO PROSTHETICS AND ORTHOTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2018
-----------------------------------------------------
Last Update Date | 03/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28350 COUNTY ROAD 317 UNIT 8
-----------------------------------------------------
City | BUENA VISTA
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81211-9261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-396-9557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 918 BELLOWS RD
-----------------------------------------------------
City | HARTSEL
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80449-8553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LARA KNUDSON
-----------------------------------------------------
Credential | MSPO, CPO
-----------------------------------------------------
Telephone | 303-396-9557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 20186000250
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------