Provider Demographics
NPI:1346424728
Name:CENTER FOR ORTHOTIC & PROSTHETIC EXCELLENCE, LLC
Entity type:Organization
Organization Name:CENTER FOR ORTHOTIC & PROSTHETIC EXCELLENCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AMIT
Authorized Official - Middle Name:
Authorized Official - Last Name:BHANTI
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:309-676-2276
Mailing Address - Street 1:741 W MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606
Mailing Address - Country:US
Mailing Address - Phone:309-676-2276
Mailing Address - Fax:888-663-6322
Practice Address - Street 1:9615 KEILMAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373
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:2007-12-20
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213.000102OtherSTATE OF ILLINOIS - LICENSED ORTHOTIST
INCO003904OtherAMERICAN BOARD FOR CERTIFICATION IN ORTHOTICS & PROSTHETICS
IL=========-001Medicaid
IL213.000102OtherSTATE OF ILLINOIS - LICENSED ORTHOTIST