Provider Demographics
NPI:1104010172
Name:OPTECH ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:OPTECH ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ORTHOTIST PROSTHOTIST PRE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCNAB
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:815-932-8564
Mailing Address - Street 1:18210 S LAGRANGE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477
Mailing Address - Country:US
Mailing Address - Phone:708-364-9700
Mailing Address - Fax:815-932-8640
Practice Address - Street 1:18210 S LAGRANGE
Practice Address - Street 2:SUITE 206
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477
Practice Address - Country:US
Practice Address - Phone:708-364-9700
Practice Address - Fax:815-932-8640
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTECH ORTHOTICS & PROSTHETICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04622011OtherBCBS
IL80544OtherNORTHWOOD UHC
IL04622011OtherBCBS
1245500001Medicare NSC