1477722445 NPI number — MIDWEST ORTHOTIC & TECHNOLOGY CENTER OMAHA, LLC

Table of content: (NPI 1477722445)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477722445 NPI number — MIDWEST ORTHOTIC & TECHNOLOGY CENTER OMAHA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MIDWEST ORTHOTIC & TECHNOLOGY CENTER OMAHA, LLC
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:
1477722445
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17530 DUGDALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11225 DAVENPORT ST
Provider Second Line Business Practice Location Address:
SUITE 106
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68154-2641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-933-3942
Provider Business Practice Location Address Fax Number:
402-964-2926
Provider Enumeration Date:
02/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VELDMAN
Authorized Official First Name:
BERNIE
Authorized Official Middle Name:
T
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
574-233-3352

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: 1--25653000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".




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