Healthcare Provider Details

I. General information

NPI: 1528096997
Provider Name (Legal Business Name): MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 LAFAYETTE AVE SE SUITE 330
GRAND RAPIDS MI
49503-4677
US

IV. Provider business mailing address

235 WEALTHY ST SE
GRAND RAPIDS MI
49503-5247
US

V. Phone/Fax

Practice location:
  • Phone: 616-356-1916
  • Fax: 616-356-1868
Mailing address:
  • Phone: 616-356-1916
  • Fax: 616-356-1868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. MARK A PORTH
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 616-356-1916