Provider Demographics
NPI:1073576617
Name:CANTON ORTHOTIC LABORATORY INC
Entity Type:Organization
Organization Name:CANTON ORTHOTIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/LICENSED ORTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SIMKO
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:330-833-0955
Mailing Address - Street 1:2400 WALES AVE NW
Mailing Address - Street 2:SUITE H
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-0804
Mailing Address - Country:US
Mailing Address - Phone:330-833-0955
Mailing Address - Fax:330-833-0980
Practice Address - Street 1:2400 WALES AVE NW
Practice Address - Street 2:SUITE H
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-0804
Practice Address - Country:US
Practice Address - Phone:330-833-0955
Practice Address - Fax:330-833-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000155415OtherANTHEM COMMUNITY MUTUAL
OH0291143Medicaid
OH=========026OtherCARE SOURCE MEDICAID HMO
OH0291143Medicaid
HI=========003OtherMEDICAL MUTUAL INSURANCE