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General NPI Number Information
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NPI Number | 1558539338
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Entity Type | Organization
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Legal Business Name | LISA E ROSTVOLD
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Dates
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Enumeration Date | 02/14/2008
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Last Update Date | 06/19/2008
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Provider Practice Location Address
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Address Line | 110 N BUFFALO ST
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City | WARSAW
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State | IN
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Zip | 46580-2754
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Country | US
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Telephone | 574-267-5537
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Fax | 574-267-6165
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Provider Business Mailing Address
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Address Line | 110 N BUFFALO ST
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City | WARSAW
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State | IN
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Zip | 46580-2754
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Country | US
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Telephone | 574-267-5537
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Fax | 574-267-6165
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Authorized Official
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Title or Position | OWNER
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Name | MS. LISA ELLEN ROSTVOLD
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Credential | CERTIFIED PEDORTHIST
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Telephone | 574-267-5537
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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 | CPED2624
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License Number State | IN
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