Provider Demographics
NPI:1497583348
Name:CENTER FOR ORTHOTIC & PROSTHETIC EXCELLENCE, LLC
Entity type:Organization
Organization Name:CENTER FOR ORTHOTIC & PROSTHETIC EXCELLENCE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:F
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-285-7752
Mailing Address - Street 1:741 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1953
Mailing Address - Country:US
Mailing Address - Phone:309-285-7752
Mailing Address - Fax:309-285-7752
Practice Address - Street 1:11065 BROADWAY STE F
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7302
Practice Address - Country:US
Practice Address - Phone:219-365-0248
Practice Address - Fax:219-365-0072
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-23
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier