Healthcare Provider Details

I. General information

NPI: 1740113422
Provider Name (Legal Business Name): FORM ORTHOTICS & PROSTHETICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 E STATE ST LOWR LEVEL
ROCKFORD IL
61108-2275
US

IV. Provider business mailing address

4921 E STATE ST LOWR LEVEL
ROCKFORD IL
61108-2275
US

V. Phone/Fax

Practice location:
  • Phone: 402-212-7878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: MICAH ALFORD
Title or Position: FOUNDER
Credential: L/CPO
Phone: 402-212-7878