Provider Demographics
NPI:1992719330
Name:CORNELL ORTHOTICS & PROSTHETICS ENTP. LLC
Entity type:Organization
Organization Name:CORNELL ORTHOTICS & PROSTHETICS ENTP. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:
Authorized Official - Last Name:CORNELL
Authorized Official - Suffix:
Authorized Official - Credentials:BOC(P) RT(P)
Authorized Official - Phone:316-684-2673
Mailing Address - Street 1:6108 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-2844
Mailing Address - Country:US
Mailing Address - Phone:316-684-2673
Mailing Address - Fax:316-941-3502
Practice Address - Street 1:6108 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-2844
Practice Address - Country:US
Practice Address - Phone:316-684-2673
Practice Address - Fax:316-941-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS5778680001Medicare NSC