Healthcare Provider Details

I. General information

NPI: 1710308200
Provider Name (Legal Business Name): GREAT LAKES ORTHOTICS AND MEDICAL SUPPLY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2013
Last Update Date: 12/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8633 W GREENFIELD AVE
WEST ALLIS WI
53214-4362
US

IV. Provider business mailing address

8633 W GREENFIELD AVE
WEST ALLIS WI
53214-4362
US

V. Phone/Fax

Practice location:
  • Phone: 262-361-4389
  • Fax:
Mailing address:
  • Phone: 262-361-4389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL BUGGY
Title or Position: PRESIDENT
Credential:
Phone: 262-227-0346