Healthcare Provider Details

I. General information

NPI: 1245571660
Provider Name (Legal Business Name): NV ORTHOTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 W DEMPSTER ST
PARK RIDGE IL
60068-1110
US

IV. Provider business mailing address

5131 ELLINGTON AVE
WESTERN SPRINGS IL
60558-2034
US

V. Phone/Fax

Practice location:
  • Phone: 708-651-2564
  • Fax:
Mailing address:
  • Phone: 708-651-2564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number04254422
License Number StateIL

VIII. Authorized Official

Name: MR. ROBERT ALLEN NOVAK
Title or Position: OWNER/ORTHOTIST
Credential: CO
Phone: 708-651-2564