=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487080974
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ORTHOTIC CARE SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2013
-----------------------------------------------------
Last Update Date | 09/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 347 SMITH AVE N STE 604
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55102-3363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-222-2679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2545 CHICAGO AVE STE 412
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55404-4566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-871-1480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COO
-----------------------------------------------------
Name | CHRISTIAN WEIDNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-799-1051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------