1245215417 NPI number — SNELL PROSTHETIC & ORTHOTIC LABORATORY

Table of content: (NPI 1245215417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245215417 NPI number — SNELL PROSTHETIC & ORTHOTIC LABORATORY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SNELL PROSTHETIC & ORTHOTIC LABORATORY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245215417
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 N UNIVERSITY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72205-2917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-664-2624
Provider Business Mailing Address Fax Number:
501-664-1708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3416 N COLLEGE AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72703-5105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-442-4435
Provider Business Practice Location Address Fax Number:
479-442-5910
Provider Enumeration Date:
12/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SNELL
Authorized Official First Name:
BRANT
Authorized Official Middle Name:
E.
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
501-664-2624

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  04734178001 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 300574716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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