Healthcare Provider Details

I. General information

NPI: 1508951880
Provider Name (Legal Business Name): ORTHOMOLD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5575 JACKSON BLVD
WHITE LAKE MI
48383-1919
US

IV. Provider business mailing address

5575 JACKSON BLVD
WHITE LAKE MI
48383-1919
US

V. Phone/Fax

Practice location:
  • Phone: 248-889-4800
  • Fax: 248-889-4800
Mailing address:
  • Phone: 248-889-4800
  • Fax: 248-889-4800

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. SAM IAFRATE
Title or Position: PRESIDENT
Credential:
Phone: 248-889-4800