Provider Demographics
NPI:1376226910
Name:MD ORTHOTIC AND PROSTHETIC LABORATORY, INC
Entity Type:Organization
Organization Name:MD ORTHOTIC AND PROSTHETIC LABORATORY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF REVENUE CYCLE MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:F
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-285-7752
Mailing Address - Street 1:741 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1953
Mailing Address - Country:US
Mailing Address - Phone:309-285-7752
Mailing Address - Fax:309-285-7752
Practice Address - Street 1:387 SHUMAN BLVD STE 201E
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8306
Practice Address - Country:US
Practice Address - Phone:630-283-1830
Practice Address - Fax:630-320-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier