Healthcare Provider Details

I. General information

NPI: 1154894046
Provider Name (Legal Business Name): LAKER PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5181 PLAINFIELD AVE NE SUITE D
GRAND RAPIDS MI
49525
US

IV. Provider business mailing address

5181 PLAINFIELD AVE NE SUITE D
GRAND RAPIDS MI
49525
US

V. Phone/Fax

Practice location:
  • Phone: 616-490-8564
  • Fax: 616-469-2962
Mailing address:
  • Phone: 616-490-8564
  • Fax: 616-469-2962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. SEAN PAUL TAYLOR
Title or Position: OWNER
Credential: CP
Phone: 616-490-8564