Healthcare Provider Details

I. General information

NPI: 1154721785
Provider Name (Legal Business Name): PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 RADIO DR STE 100
WOODBURY MN
55125-5817
US

IV. Provider business mailing address

PO BOX 947109
ATLANTA GA
30394-7109
US

V. Phone/Fax

Practice location:
  • Phone: 612-593-6205
  • Fax: 612-335-5396
Mailing address:
  • Phone: 813-367-2876
  • Fax: 813-518-7659

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: MR. JEFFREY J BRUCE
Title or Position: MANAGER
Credential: CPO
Phone: 612-596-6205