Provider Demographics
NPI:1366517450
Name:ORTHOMEDICAL, INC
Entity type:Organization
Organization Name:ORTHOMEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-785-4595
Mailing Address - Street 1:PO BOX 1127
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1127
Mailing Address - Country:US
Mailing Address - Phone:208-785-4595
Mailing Address - Fax:208-785-4595
Practice Address - Street 1:1053 W BRIDGE ST
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1915
Practice Address - Country:US
Practice Address - Phone:208-785-4595
Practice Address - Fax:208-785-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDDME200332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805979000Medicaid
ID4387480001Medicare NSC