Healthcare Provider Details

I. General information

NPI: 1235139528
Provider Name (Legal Business Name): ORTHOTIC AND PROSTHETIC LAB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 MARSHALL AVE
WEBSTER GROVES MO
63119-1924
US

IV. Provider business mailing address

748 MARSHALL AVE
WEBSTER GROVES MO
63119-1924
US

V. Phone/Fax

Practice location:
  • Phone: 314-968-8555
  • Fax:
Mailing address:
  • Phone: 314-968-8555
  • Fax:

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 TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number211.000024
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number213.000099
License Number StateIL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier621818608
Identifier TypeMEDICAID
Identifier StateMO
Identifier Issuer

VIII. Authorized Official

Name: MR. DAVID J OSTERMAN
Title or Position: PRESIDENT
Credential:
Phone: 314-968-8555