1649322512 NPI number — MD ORTHOTIC AND PROSTHETIC LAB

Table of content: (NPI 1649322512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649322512 NPI number — MD ORTHOTIC AND PROSTHETIC LAB

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD ORTHOTIC AND PROSTHETIC LAB
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:
1649322512
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8400 BROOKFIELD AVE
Provider Second Line Business Mailing Address:
1ST FLOOR
Provider Business Mailing Address City Name:
BROOKFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60513-1707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-387-9700
Provider Business Mailing Address Fax Number:
708-387-9704

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 N HAMMES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOLIET
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-387-9700
Provider Business Practice Location Address Fax Number:
708-387-9704
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOERTZEN
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
309-676-2276

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  060008643213000063 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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