Healthcare Provider Details

I. General information

NPI: 1487634580
Provider Name (Legal Business Name): SUBURBAN ORTHOTICS & PROSTHETICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 LEE ST
DES PLAINES IL
60016-4615
US

IV. Provider business mailing address

450 LEE ST
DES PLAINES IL
60016-4615
US

V. Phone/Fax

Practice location:
  • Phone: 847-298-7107
  • Fax: 847-298-6072
Mailing address:
  • Phone: 847-298-7107
  • Fax: 847-298-6072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateIL

VIII. Authorized Official

Name: MR. RYAN J CALDWELL
Title or Position: PRESIDENT
Credential:
Phone: 847-298-7107