Provider Demographics
NPI:1992818009
Name:PEDORTHIC SERVICES, LLC
Entity type:Organization
Organization Name:PEDORTHIC SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:859-266-0420
Mailing Address - Street 1:371 SOUTHLAND DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1824
Mailing Address - Country:US
Mailing Address - Phone:859-266-0420
Mailing Address - Fax:859-266-0667
Practice Address - Street 1:371 SOUTHLAND DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1824
Practice Address - Country:US
Practice Address - Phone:859-266-0420
Practice Address - Fax:859-266-0667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000519294OtherANTHEM BC/BS
KY5574649OtherAETNA
KY7100026770Medicaid
KY74928OtherUNITED HEALTHCARE
KY5939230001OtherMEDICARE DME
KY000000519294OtherANTHEM BC/BS
KY5939230001OtherMEDICARE DME
KY000000519294OtherANTHEM BC/BS
KY5574649OtherAETNA