1417364100 NPI number — NORTHERN ORTHOTIC AND PROSTHETIC CENTER

Table of content: (NPI 1417364100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417364100 NPI number — NORTHERN ORTHOTIC AND PROSTHETIC CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN ORTHOTIC AND PROSTHETIC CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417364100
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1279 S POKEGAMA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55744-4208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-301-0001
Provider Business Mailing Address Fax Number:
218-301-0044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1279 S POKEGAMA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55744-4208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-301-0001
Provider Business Practice Location Address Fax Number:
218-301-0044
Provider Enumeration Date:
07/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FRANCISCO
Authorized Official First Name:
GREGORY
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
ORTHOTIST/OWNER
Authorized Official Telephone Number:
218-249-6250

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com