Basic Information
| Provider Information | |||||||||
| NPI: | 1952477101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROSTHETIC ILLUSIONS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3405 S YARROW ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802274965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039738482 | ||||||||
| FaxNumber: | 3039738468 | ||||||||
| Practice Location | |||||||||
| Address1: | 3405 S YARROW ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802274965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3039738482 | ||||||||
| FaxNumber: | 3039738468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LILLO | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3039738482 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CCA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
No ID Information.