Provider Demographics
NPI:1336117746
Name:BRENNER ORTHOTIC & PROSTHETIC LABORATORIES INC
Entity Type:Organization
Organization Name:BRENNER ORTHOTIC & PROSTHETIC LABORATORIES INC
Other - Org Name:MICHIGAN INSTITUTE FOR ELECTRONIC LIMB DEVELOPMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRENNER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO FAAOP
Authorized Official - Phone:248-615-0601
Mailing Address - Street 1:32975 8 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1337
Mailing Address - Country:US
Mailing Address - Phone:248-615-0601
Mailing Address - Fax:248-615-0606
Practice Address - Street 1:32975 8 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1337
Practice Address - Country:US
Practice Address - Phone:248-615-0601
Practice Address - Fax:248-615-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0461990001Medicaid
MI0461990001Medicaid
0461990001Medicare ID - Type Unspecified