MEDICARE: CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier	NA	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083944672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR ORTHOTIC AND PROSTHETIC CARE OF KY, LLC

Provider Business Mailing Address
First Line	:	P O BOX 650846
Second Line	:	SUITE 100
City	:	DALLAS
State	:	TX
Zip	:	75265-0846
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	130 STONECREST RD
Second Line	:	SUITE 104
City	:	SHELBYVILLE
State	:	KY
Zip	:	40065-8126
Country	:	US
Telephone Number	:	502-899-9221
Fax Number	:	502-899-9468

Authorized Official
Title or Position	:	REG COMPLIANCE SPECIALIST III
Name	:	GRACE ANGELINE
Credential	:
Telephone Number	:	714-961-2102

Provider Enumeration Date	:	01/05/2010
Last Update Date	:	01/07/2022

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