Provider Demographics
NPI:1902993124
Name:AKBK
Entity Type:Organization
Organization Name:AKBK
Other - Org Name:CROCKETT PROSTHETICS & ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:KOSLOSKI
Authorized Official - Suffix:
Authorized Official - Credentials:CPO,FAAOP
Authorized Official - Phone:865-688-2626
Mailing Address - Street 1:4503 WALKER BLVD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-1526
Mailing Address - Country:US
Mailing Address - Phone:865-688-2626
Mailing Address - Fax:865-688-3647
Practice Address - Street 1:10932 MURDOCK DR
Practice Address - Street 2:SUITE 105A
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-3239
Practice Address - Country:US
Practice Address - Phone:865-675-2873
Practice Address - Fax:865-675-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3555750Medicaid
TN86519OtherBLUE CROSS BLUE SHIELD
TN0448920003Medicare NSC