MEDICARE: ORTHOMOLD INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)		MI

General Provider Information

NPI Number	:	1508951880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOMOLD INC

Provider Business Mailing Address
First Line	:	5575 JACKSON BLVD
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1919
Country	:	US
Telephone Number	:	248-889-4800
Fax Number	:	248-889-4800

Provider Business Practice Location Address
First Line	:	5575 JACKSON BLVD
Second Line	:
City	:	WHITE LAKE
State	:	MI
Zip	:	48383-1919
Country	:	US
Telephone Number	:	248-889-4800
Fax Number	:	248-889-4800

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. SAM IAFRATE
Credential	:
Telephone Number	:	248-889-4800

Provider Enumeration Date	:	10/04/2006
Last Update Date	:	07/21/2022

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Directions to “ORTHOMOLD INC ” Practice Location

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