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General NPI Number Information
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NPI Number | 1649322512
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Entity Type | Organization
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Legal Business Name | MD ORTHOTIC AND PROSTHETIC LAB
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 07/30/2018
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Provider Practice Location Address
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Address Line | 227 N HAMMES AVE
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City | JOLIET
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State | IL
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Zip | 60435
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Country | US
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Telephone | 708-387-9700
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Fax | 708-387-9704
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Provider Business Mailing Address
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Address Line | 8400 BROOKFIELD AVE 1ST FLOOR
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City | BROOKFIELD
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State | IL
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Zip | 60513-1707
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Country | US
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Telephone | 708-387-9700
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Fax | 708-387-9704
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Authorized Official
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Title or Position | PRESIDENT
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Name | DONALD GOERTZEN
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Credential |
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Telephone | 309-676-2276
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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 | 060008643213000063
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License Number State | IL
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