Healthcare Provider Details

I. General information

NPI: 1508608167
Provider Name (Legal Business Name): MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 MUNSON AVE STE M100A
TRAVERSE CITY MI
49686-3580
US

IV. Provider business mailing address

235 WEALTHY ST SE STE 1100
GRAND RAPIDS MI
49503-5247
US

V. Phone/Fax

Practice location:
  • Phone: 231-715-4755
  • Fax:
Mailing address:
  • Phone: 616-617-0538
  • 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: ROBERT TUCK
Title or Position: COMPLIANCE DIRECTOR
Credential: CPO
Phone: 616-502-6488