Provider Demographics
NPI:1164685475
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:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-281-5250
Mailing Address - Street 1:831 CRITTER CT
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ONALASKA
Mailing Address - State:WI
Mailing Address - Zip Code:54650-8674
Mailing Address - Country:US
Mailing Address - Phone:608-783-2009
Mailing Address - Fax:608-781-2128
Practice Address - Street 1:831 CRITTER CT
Practice Address - Street 2:SUITE 300
Practice Address - City:ONALASKA
Practice Address - State:WI
Practice Address - Zip Code:54650-8674
Practice Address - Country:US
Practice Address - Phone:608-783-2009
Practice Address - Fax:608-781-2128
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GMS OF ROCHESTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-07
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1164685475Medicaid
WI41794100Medicaid
WI41794100Medicaid