Provider Demographics
NPI:1891820882
Name:SPRINGFIELD ORTHOTICS AND PROSTHETICS INC
Entity type:Organization
Organization Name:SPRINGFIELD ORTHOTICS AND PROSTHETICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:417-889-3222
Mailing Address - Street 1:2100 S BRENTWOOD BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2534
Mailing Address - Country:US
Mailing Address - Phone:417-889-3222
Mailing Address - Fax:417-889-3223
Practice Address - Street 1:2100 S BRENTWOOD BLVD STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2534
Practice Address - Country:US
Practice Address - Phone:417-889-3222
Practice Address - Fax:417-889-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1035050001Medicare ID - Type UnspecifiedPROVIDER NUMBER