=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992818009
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDORTHIC SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2006
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 371 SOUTHLAND DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-266-0420
-----------------------------------------------------
Fax | 859-266-0667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 371 SOUTHLAND DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-266-0420
-----------------------------------------------------
Fax | 859-266-0667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. LARRY WHEELER
-----------------------------------------------------
Credential | C.PED
-----------------------------------------------------
Telephone | 859-266-0420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------