=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033261912
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MD ORTHOTIC AND PROSTHETIC LABORATORIES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2007
-----------------------------------------------------
Last Update Date | 09/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 387 SHUMAN BLVD STE 201E
-----------------------------------------------------
City | NAPERVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60563-8306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-283-1830
-----------------------------------------------------
Fax | 630-320-2282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 741 W MAIN ST
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61606-1953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-334-5705
-----------------------------------------------------
Fax | 888-663-6322
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | AMIT BHANTI
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 309-676-2276
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 060008643213000063
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------