Provider Demographics
NPI:1316198682
Name:PROSTHETIC ORTHOTIC CENTER
Entity Type:Organization
Organization Name:PROSTHETIC ORTHOTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:KARL
Authorized Official - Last Name:LOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, FAAOP
Authorized Official - Phone:715-432-7787
Mailing Address - Street 1:1108 S 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-5709
Mailing Address - Country:US
Mailing Address - Phone:715-845-2800
Mailing Address - Fax:715-845-2855
Practice Address - Street 1:9815 HWY 70 STE 101
Practice Address - Street 2:
Practice Address - City:MINOCQUA
Practice Address - State:WI
Practice Address - Zip Code:54548-9769
Practice Address - Country:US
Practice Address - Phone:715-356-3377
Practice Address - Fax:715-845-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41782800Medicaid
WI0251680003Medicare NSC