Provider Demographics
NPI:1053461863
Name:ORTHOTIC AND PROSTHETIC HEALTH
Entity Type:Organization
Organization Name:ORTHOTIC AND PROSTHETIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:605-886-3272
Mailing Address - Street 1:810 S MAPLE
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201-4859
Mailing Address - Country:US
Mailing Address - Phone:605-886-3272
Mailing Address - Fax:218-847-7676
Practice Address - Street 1:810 S MAPLE
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:SD
Practice Address - Zip Code:57201-4859
Practice Address - Country:US
Practice Address - Phone:605-886-3272
Practice Address - Fax:218-847-7676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9162720Medicaid
SD9162720Medicaid