Healthcare Provider Details

I. General information

NPI: 1750359048
Provider Name (Legal Business Name): OPTECH ORTHOTICS & PROSTHETICS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 E COURT ST STE 100
KANKAKEE IL
60901-3823
US

IV. Provider business mailing address

119 E COURT ST STE 100
KANKAKEE IL
60901-3823
US

V. Phone/Fax

Practice location:
  • Phone: 815-932-8564
  • Fax: 815-932-8640
Mailing address:
  • Phone: 815-932-8564
  • Fax: 815-932-8640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MARTIN B MCNAB JR.
Title or Position: CERTIFIED ORTHOTIST PROSTHETIST
Credential: CPO
Phone: 815-932-8564