1467454959 NPI number — PROSTHETIC CENTER, INC.

Table of content: (NPI 1467454959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467454959 NPI number — PROSTHETIC CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSTHETIC CENTER, INC.
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:
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:
1467454959
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 S WASHINGTON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48910-1651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-372-7007
Provider Business Mailing Address Fax Number:
517-372-0261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 S WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48910-1651
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-372-7007
Provider Business Practice Location Address Fax Number:
517-372-0261
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
JUNTTONEN
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
W.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
517-372-7007

Provider Taxonomy Codes

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

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

  • Identifier: 1904003 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P58725 . This is a "BLUE CHOIC" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 520C303120 . This is a "BLUE CROSS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 650 . This is a "NORTHWOOD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P58725 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 52547 . This is a "NORTHWOOD/NPN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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