Healthcare Provider Details

I. General information

NPI: 1851389449
Provider Name (Legal Business Name): PROSTHETIC ORTHOTIC SPECIALIST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2005
Last Update Date: 07/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 NE JEFFERSON AVE
PEORIA IL
61603
US

IV. Provider business mailing address

741 W MAIN ST
PEORIA IL
61606-1953
US

V. Phone/Fax

Practice location:
  • Phone: 309-688-9549
  • Fax: 309-676-0486
Mailing address:
  • Phone: 309-676-2276
  • Fax: 309-676-0486

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