MEDICARE: MR. RICHARD SHANE COLTRAIN CPO

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	224P00000X	Prosthetist	CPO 2469	VA
2	222Z00000X	Orthotist	CPO 2469	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ABC CPO 2469	OTHER	NC	INDIVIDUAL ABC CERTIFICATION#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0464J	OTHER	NC	NC BCBS PROVIDER#

General Provider Information

NPI Number	:	1417994500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD SHANE COLTRAIN CPO

Provider Business Mailing Address
First Line	:	1025 WH SMITH BLVD
Second Line	:	SUITE 108
City	:	GREENVILLE
State	:	NC
Zip	:	27834-5052
Country	:	US
Telephone Number	:	252-215-2215
Fax Number	:	252-215-2216

Provider Business Practice Location Address
First Line	:	1025 WH SMITH BLVD
Second Line	:	SUITE 108
City	:	GREENVILLE
State	:	NC
Zip	:	27834-5052
Country	:	US
Telephone Number	:	252-215-2215
Fax Number	:	252-215-2216

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2006
Last Update Date	:	04/03/2013

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