Healthcare Provider Details

I. General information

NPI: 1881746758
Provider Name (Legal Business Name): MD ORTHOTIC AND PROSTHETIC LABORATORY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 W PETERSON AVE STE 402
CHICAGO IL
60646
US

IV. Provider business mailing address

741 W MAIN ST
PEORIA IL
61606-1953
US

V. Phone/Fax

Practice location:
  • Phone: 773-545-6047
  • Fax: 888-635-3135
Mailing address:
  • Phone: 800-334-5705
  • Fax: 888-663-6322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number060008643213000063
License Number StateIL

VIII. Authorized Official

Name: MR. DONALD GOERTZEN
Title or Position: PRESIDENT
Credential: CPO
Phone: 309-676-2276