=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295124865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSTHETIC LABORATORIES OF ROCHESTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2015
-----------------------------------------------------
Last Update Date | 03/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 W CENTER ST
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55902-3031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-289-1512
-----------------------------------------------------
Fax | 507-289-2038
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 23RD AVE SW SUITE 101
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55902-0998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-289-1512
-----------------------------------------------------
Fax | 507-289-2038
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF REIMBURSEMENT
-----------------------------------------------------
Name | SHERYL PRICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 503-493-8288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------