Provider Demographics
NPI:1063990927
Name:ORTHOTIC LAB
Entity type:Organization
Organization Name:ORTHOTIC LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RHODES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-332-5500
Mailing Address - Street 1:800 8TH AVE STE 536
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2604
Mailing Address - Country:US
Mailing Address - Phone:817-332-5500
Mailing Address - Fax:817-332-5503
Practice Address - Street 1:800 8TH AVE STE 536
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2604
Practice Address - Country:US
Practice Address - Phone:817-332-5500
Practice Address - Fax:817-332-5503
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR KEVIN D RHODES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103849906Medicaid