Healthcare Provider Details

I. General information

NPI: 1497929434
Provider Name (Legal Business Name): SRT PROSTHETICS & ORTHOTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 N. FRONT ST. SUITE F
MCHENRY IL
60050
US

IV. Provider business mailing address

408 E WASHINGTON ST
BUTLER IN
46721-1179
US

V. Phone/Fax

Practice location:
  • Phone: 815-679-6900
  • Fax: 419-633-3961
Mailing address:
  • Phone: 419-633-3961
  • Fax: 419-633-3981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LESLIE SIEBENALER
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 866-633-3961