Provider Demographics
NPI:1548545585
Name:INNOVATIVE PROSTHETICS & ORTHOTICS OF GRAND ISLAND, LLC
Entity type:Organization
Organization Name:INNOVATIVE PROSTHETICS & ORTHOTICS OF GRAND ISLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-461-4931
Mailing Address - Street 1:1213 ALLEN DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-3333
Mailing Address - Country:US
Mailing Address - Phone:308-675-1508
Mailing Address - Fax:308-675-1509
Practice Address - Street 1:1213 ALLEN DR
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-3333
Practice Address - Country:US
Practice Address - Phone:308-675-1508
Practice Address - Fax:308-675-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-20
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier