MEDICARE: FIRST CHOICE ORTHOTICS AND PROSTHETICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	222Z00000X	Orthotist
2	224P00000X	Prosthetist

General Provider Information

NPI Number	:	1063881530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST CHOICE ORTHOTICS AND PROSTHETICS

Provider Business Mailing Address
First Line	:	30161 N PARK DR
Second Line	:	APT 104
City	:	CHESTERFIELD
State	:	MI
Zip	:	48047-1398
Country	:	US
Telephone Number	:	313-424-3032
Fax Number	:	586-439-0183

Provider Business Practice Location Address
First Line	:	19189 15 MILE RD
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48035-2508
Country	:	US
Telephone Number	:	866-925-2696
Fax Number	:	586-439-0183

Authorized Official
Title or Position	:	ORTHOTIC PROSTHETIC PRACTITIONER
Name	:	MR. CHARLES WILLIAMS
Credential	:	CPO
Telephone Number	:	313-424-3032

Provider Enumeration Date	:	09/15/2015
Last Update Date	:	09/15/2015

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