Healthcare Provider Details

I. General information

NPI: 1932652567
Provider Name (Legal Business Name): MD ORTHOTIC & PROSTHETIC LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2016
Last Update Date: 09/02/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8741 S GREENWOOD AVE STE 101
CHICAGO IL
60619-7058
US

IV. Provider business mailing address

741 W MAIN ST
PEORIA IL
61606-1953
US

V. Phone/Fax

Practice location:
  • Phone: 773-779-5869
  • Fax: 773-779-8869
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 Number211000147
License Number StateIL

VIII. Authorized Official

Name: KENDRA F MICKELSON
Title or Position: MANAGER OF REVENUE CYCLE MANAGEMENT
Credential:
Phone: 309-285-7752