Healthcare Provider Details

I. General information

NPI: 1154649325
Provider Name (Legal Business Name): ORTHOTICS AND PROSTHETICS ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 DELAFIELD ST SUITE 200
WAUKESHA WI
53188-3417
US

IV. Provider business mailing address

10506 W BLUEMOUND RD
MILWAUKEE WI
53226-4332
US

V. Phone/Fax

Practice location:
  • Phone: 262-436-0079
  • Fax: 262-436-0073
Mailing address:
  • Phone: 414-257-2727
  • Fax: 414-257-9898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberC.P. 1307
License Number StateWI

VIII. Authorized Official

Name: JAKE RICHARD WOOD
Title or Position: PRESIDENT
Credential: C.P., F.A.A.O.P.
Phone: 262-436-0079