1932652567 NPI number — MD ORTHOTIC & PROSTHETIC LABORATORY, INC.

Table of content: (NPI 1932652567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932652567 NPI number — MD ORTHOTIC & PROSTHETIC LABORATORY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD ORTHOTIC & PROSTHETIC LABORATORY, 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:
1932652567
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:
8741 S GREENWOOD AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICAGO
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60619-7058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-779-5869
Provider Business Practice Location Address Fax Number:
773-779-8869
Provider Enumeration Date:
08/01/2016

Additional Information

Authorized Official

Authorized Official Last Name:
MICKELSON
Authorized Official First Name:
KENDRA
Authorized Official Middle Name:
F
Authorized Official Title or Position:
MANAGER OF REVENUE CYCLE MANAGEMENT
Authorized Official Telephone Number:
309-285-7752

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  211000147 , 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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