Provider Demographics
NPI:1801942354
Name:IDAHO ORTHOTIC PROSTHETIC SERVICES, INC
Entity type:Organization
Organization Name:IDAHO ORTHOTIC PROSTHETIC SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-765-5081
Mailing Address - Street 1:8880 SW NIMBUS AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7111
Mailing Address - Country:US
Mailing Address - Phone:503-765-5081
Mailing Address - Fax:503-765-5081
Practice Address - Street 1:425 S WHITLEY DR STE 431
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2611
Practice Address - Country:US
Practice Address - Phone:208-884-1294
Practice Address - Fax:208-884-1293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010148826OtherBLUE SHIELD IDAHO
ID8K537OtherTRUE BLUE BLUE CROSS IDAH
ID807031400Medicaid
OR277882Medicaid
ID8K537OtherBLUE CROSS IDAHO
ID8K537OtherTRUE BLUE BLUE CROSS IDAH
ID807031400Medicaid