Provider Demographics
NPI:1811264674
Name:MOBILE PROSTHETICS OF KENTUCKY
Entity type:Organization
Organization Name:MOBILE PROSTHETICS OF KENTUCKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:LCP
Authorized Official - Phone:270-465-8522
Mailing Address - Street 1:610 W MAIN ST
Mailing Address - Street 2:STE E
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-2501
Mailing Address - Country:US
Mailing Address - Phone:270-465-8522
Mailing Address - Fax:270-465-8523
Practice Address - Street 1:610 W MAIN ST
Practice Address - Street 2:STE E
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2501
Practice Address - Country:US
Practice Address - Phone:270-465-8522
Practice Address - Fax:270-465-8523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100209830Medicaid
KY000000788517OtherATHEM BLUE CROSS AND BLUE SHIELD
KY000000788517OtherATHEM BLUE CROSS AND BLUE SHIELD