Provider Demographics
NPI:1033718192
Name:PRAIRIE RIDGE ORTHOPEDIC
Entity Type:Organization
Organization Name:PRAIRIE RIDGE ORTHOPEDIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JODY
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZEL
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:618-302-1703
Mailing Address - Street 1:1750 E COLBORN CAMP LN
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:IL
Mailing Address - Zip Code:62868-2348
Mailing Address - Country:US
Mailing Address - Phone:618-302-1703
Mailing Address - Fax:
Practice Address - Street 1:1750 E COLBORN CAMP LN
Practice Address - Street 2:
Practice Address - City:NOBLE
Practice Address - State:IL
Practice Address - Zip Code:62868-2348
Practice Address - Country:US
Practice Address - Phone:618-302-1703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty