Provider Demographics
NPI:1699714592
Name:SUSAN ELAINE MITCHELL
Entity type:Organization
Organization Name:SUSAN ELAINE MITCHELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CERTIFIED PEDORTHIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:573-348-6767
Mailing Address - Street 1:1018 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3033
Mailing Address - Country:US
Mailing Address - Phone:573-348-6767
Mailing Address - Fax:573-348-6767
Practice Address - Street 1:1018 MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3033
Practice Address - Country:US
Practice Address - Phone:573-348-6767
Practice Address - Fax:573-348-6767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier