Healthcare Provider Details

I. General information

NPI: 1811988652
Provider Name (Legal Business Name): PROSTHETIC LABORATORIES OF ROCHESTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 2ND AVE SW STE 115
ROCHESTER MN
55902-3027
US

IV. Provider business mailing address

PO BOX 650846
DALLAS TX
75265-0846
US

V. Phone/Fax

Practice location:
  • Phone: 507-289-1512
  • Fax: 507-289-2083
Mailing address:
  • Phone: 507-289-1512
  • Fax: 507-289-2083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: SHERYL PRICE
Title or Position: DIRECTOR OF REIMBURSEMENT
Credential:
Phone: 503-493-8288