Healthcare Provider Details

I. General information

NPI: 1205138625
Provider Name (Legal Business Name): NORTHERN ORTHOTICS & PROSTHETICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20075 3RD ST
HANCOCK MI
49930-9805
US

IV. Provider business mailing address

509 S SUPERIOR AVE
BARAGA MI
49908-9698
US

V. Phone/Fax

Practice location:
  • Phone: 906-482-7733
  • Fax:
Mailing address:
  • Phone: 906-353-7161
  • Fax: 906-353-7000

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: THOMAS PENFOLD
Title or Position: PRESIDENT
Credential: CPO
Phone: 906-353-7161