Provider Demographics
NPI:1326524745
Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Other - Org Name:MARY FREE BED ORTHOTICS AND PROSTHETICS LANSING
Other - Org Type:Other Name
Authorized Official - Title/Position:COMPLIANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PORTH
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:616-840-8433
Mailing Address - Street 1:235 WEALTHY ST SE STE 1100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8433
Mailing Address - Fax:616-840-9504
Practice Address - Street 1:1219 E SAGINAW ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48906-5523
Practice Address - Country:US
Practice Address - Phone:517-485-5877
Practice Address - Fax:616-840-9504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthistGroup - Multi-Specialty
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty