Provider Demographics
NPI:1275935207
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHWEST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTTMANN
Authorized Official - Suffix:
Authorized Official - Credentials:BOCP, CPOA
Authorized Official - Phone:314-432-3600
Mailing Address - Street 1:PO BOX 865109
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-5109
Mailing Address - Country:US
Mailing Address - Phone:844-602-3960
Mailing Address - Fax:813-281-8461
Practice Address - Street 1:4400 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1624
Practice Address - Country:US
Practice Address - Phone:314-872-7891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - NORTHWEST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-22
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier