1679625560 NPI number — MD ORTHOTIC AND PROSTHETIC LABORATORIES, INC.

Table of content: (NPI 1679625560)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679625560 NPI number — MD ORTHOTIC AND PROSTHETIC LABORATORIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD ORTHOTIC AND PROSTHETIC LABORATORIES, 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:
1679625560
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
741 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61606-1953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-334-5705
Provider Business Mailing Address Fax Number:
888-663-6322

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3077 W JEFFERSON ST STE 101
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:
60435-5263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
779-545-2270
Provider Business Practice Location Address Fax Number:
779-601-0195
Provider Enumeration Date:
01/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BHANTI
Authorized Official First Name:
AMIT
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
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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