Provider Demographics
NPI:1285852004
Name:CLEARWATER ORTHOTICS AND PROSTHETICS, LLC
Entity type:Organization
Organization Name:CLEARWATER ORTHOTICS AND PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-357-5732
Mailing Address - Street 1:PO BOX 2620
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-2620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 BRYDEN AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4927
Practice Address - Country:US
Practice Address - Phone:208-798-4605
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805399000Medicaid
WA9047259Medicaid
ID000010028073OtherREGENCE BLUE SHIELD OF ID
WA135273OtherL&I
ID8M820OtherBLUE CROSS OF IDAHO
WA9047259Medicaid