Healthcare Provider Details

I. General information

NPI: 1174874143
Provider Name (Legal Business Name): NORTHERN ORTHOTICS & PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 COMMERCE DR
MARQUETTE MI
49855-8694
US

IV. Provider business mailing address

1015 COMMERCE DR
MARQUETTE MI
49855-8694
US

V. Phone/Fax

Practice location:
  • Phone: 906-273-2444
  • Fax:
Mailing address:
  • Phone: 906-273-2444
  • 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: JEFFERY J ROY
Title or Position: PRESIDENT
Credential: C.P.O.
Phone: 906-353-7161