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General NPI Number Information
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NPI Number | 1184992190
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Entity Type | Organization
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Legal Business Name | MIDWEST ORTHOTIC SERVICES LLC
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Dates
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Enumeration Date | 12/05/2011
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Last Update Date | 12/05/2011
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Provider Practice Location Address
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Address Line | 611 E DOUGLAS RD
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City | MISHAWAKA
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State | IN
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Zip | 46545-1464
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Country | US
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Telephone | 574-204-2416
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Fax |
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Provider Business Mailing Address
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Address Line | 17530 DUGDALE DR
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City | SOUTH BEND
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State | IN
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Zip | 46635-1583
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Country | US
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Telephone | 574-233-3352
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Fax |
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Authorized Official
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Title or Position | DIR OF OPERATIONS
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Name | TIM COSTELLO
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Credential |
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Telephone | 574-233-3352
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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