Provider Demographics
NPI:1942378328
Name:ORTHOTICS AT HOME, INC
Entity type:Organization
Organization Name:ORTHOTICS AT HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:K
Authorized Official - Last Name:MCNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, FAAOP
Authorized Official - Phone:501-803-3555
Mailing Address - Street 1:6001 NIGHTHAWK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72118-1733
Mailing Address - Country:US
Mailing Address - Phone:501-803-3555
Mailing Address - Fax:501-803-9555
Practice Address - Street 1:6001 NIGHTHAWK RD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72118-1733
Practice Address - Country:US
Practice Address - Phone:501-803-3555
Practice Address - Fax:501-803-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARNONE REQUIRED332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49862OtherBLUE CROSS BLUE SHIELD
AR49862OtherBLUE CROSS BLUE SHIELD
AR4543230001Medicare ID - Type Unspecified