Provider Demographics
NPI:1174527162
Name:ADVANCED ORTHOTICS AND PROSTHETICS
Entity type:Organization
Organization Name:ADVANCED ORTHOTICS AND PROSTHETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:W
Authorized Official - Last Name:IKERD
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:417-239-2999
Mailing Address - Street 1:PO BOX 4331
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-4331
Mailing Address - Country:US
Mailing Address - Phone:417-627-0999
Mailing Address - Fax:417-627-0938
Practice Address - Street 1:215 S 2ND ST
Practice Address - Street 2:STE C
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2860
Practice Address - Country:US
Practice Address - Phone:417-239-2999
Practice Address - Fax:417-239-2938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4188360003Medicare ID - Type UnspecifiedALL REGIONS