MEDICARE: CROWN CRANIAL & ORTHOTICS, LLC

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1598452468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN CRANIAL & ORTHOTICS, LLC

Provider Business Mailing Address
First Line	:	1148 JEANNE CT
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-0027
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1450 E JOLIET ST STE 206
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-4726
Country	:	US
Telephone Number	:	219-801-3937
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KELLY ANN ROTH
Credential	:
Telephone Number	:	630-715-4164

Provider Enumeration Date	:	04/20/2023
Last Update Date	:	03/04/2026

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