Healthcare Provider Details

I. General information

NPI: 1649386293
Provider Name (Legal Business Name): ORTHOTIC & PROSTHETIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 FRONT ST W
DETROIT LAKES MN
56501-3020
US

IV. Provider business mailing address

810 S MAPLE ST
WATERTOWN SD
57201
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-6767
  • Fax: 218-847-7676
Mailing address:
  • Phone: 605-886-3272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberCO1105
License Number StateMN

VIII. Authorized Official

Name: MR. ROBERT E JOHANSEN
Title or Position: PRESIDENT
Credential: CO
Phone: 218-847-6767