Healthcare Provider Details

I. General information

NPI: 1699159624
Provider Name (Legal Business Name): MD ORTHOTIC AND PROSTHETIC LABORATORY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2015
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20060 GOVERNORS DR STE 102
OLYMPIA FIELDS IL
60461
US

IV. Provider business mailing address

741 W MAIN ST
PEORIA IL
61606-1953
US

V. Phone/Fax

Practice location:
  • Phone: 219-736-8896
  • Fax: 219-293-8613
Mailing address:
  • Phone: 309-676-2276
  • Fax: 888-663-6322

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: DONALD GOERTZEN
Title or Position: PRESIDENT
Credential: CPO
Phone: 309-676-2276