Provider Demographics
NPI:1023009867
Name:PROSTHETIC LABORATORIES OF ROCHESTER INC
Entity Type:Organization
Organization Name:PROSTHETIC LABORATORIES OF ROCHESTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-281-5250
Mailing Address - Street 1:1517 N OAK AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1301
Mailing Address - Country:US
Mailing Address - Phone:715-384-8030
Mailing Address - Fax:715-384-7818
Practice Address - Street 1:1517 N OAK AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1301
Practice Address - Country:US
Practice Address - Phone:715-384-8030
Practice Address - Fax:715-384-7818
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GMS OF ROCHESTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-01
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41790900Medicaid
MN0146110010Medicare NSC