Provider Demographics
NPI:1417364100
Name:NORTHERN ORTHOTIC AND PROSTHETIC CENTER
Entity Type:Organization
Organization Name:NORTHERN ORTHOTIC AND PROSTHETIC CENTER
Other - Org Name:NORTHERN ORTHOTIC AND PROSTHETIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHOTIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FRANCISCO
Authorized Official - Suffix:
Authorized Official - Credentials:BS,CO
Authorized Official - Phone:218-249-6250
Mailing Address - Street 1:1279 S POKEGAMA AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4208
Mailing Address - Country:US
Mailing Address - Phone:218-301-0001
Mailing Address - Fax:218-301-0044
Practice Address - Street 1:1279 S POKEGAMA AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4208
Practice Address - Country:US
Practice Address - Phone:218-301-0001
Practice Address - Fax:218-301-0044
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHERN ORTHOTIC AND PROSTHETIC SERVICES CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-15
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment