Healthcare Provider Details

I. General information

NPI: 1679625560
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: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3077 W JEFFERSON ST STE 101
JOLIET IL
60435-5263
US

IV. Provider business mailing address

741 W MAIN ST
PEORIA IL
61606-1953
US

V. Phone/Fax

Practice location:
  • Phone: 779-545-2270
  • Fax: 779-601-0195
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: AMIT BHANTI
Title or Position: CEO
Credential: CPO
Phone: 309-676-2276