MEDICARE: CANTON ORTHOTIC LABORATORY 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	335E00000X	Prosthetic/Orthotic Supplier
2	335E00000X	Prosthetic/Orthotic Supplier		OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000155415	OTHER	OH	ANTHEM PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720080005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANTON ORTHOTIC LABORATORY INC

Provider Business Mailing Address
First Line	:	811 12TH ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44703-1927
Country	:	US
Telephone Number	:	330-454-2081
Fax Number	:	330-454-9568

Provider Business Practice Location Address
First Line	:	811 12TH ST NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44703-1927
Country	:	US
Telephone Number	:	330-454-2081
Fax Number	:	330-454-9568

Authorized Official
Title or Position	:	PRESIDENT/LICENSED ORTHOTIST
Name	:	MR. STEPHEN THOMAS SIMKO
Credential	:	LO
Telephone Number	:	330-454-2081

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	08/22/2020

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Directions to “CANTON ORTHOTIC LABORATORY INC ” Practice Location

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