Provider Demographics
NPI:1053551432
Name:ARK VALLEY ORTHOTICS AND PROSTHETICS, LLC
Entity type:Organization
Organization Name:ARK VALLEY ORTHOTICS AND PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:316-630-8420
Mailing Address - Street 1:12911 E 21ST ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67230-7408
Mailing Address - Country:US
Mailing Address - Phone:316-630-8420
Mailing Address - Fax:316-630-0410
Practice Address - Street 1:12911 E 21ST ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67230-7408
Practice Address - Country:US
Practice Address - Phone:316-630-8420
Practice Address - Fax:316-630-0410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-25
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS6228800001Medicare NSC