Provider Demographics
NPI:1427212471
Name:ORTHOTIC AND PROSTHETIC LAB, INC.
Entity Type:Organization
Organization Name:ORTHOTIC AND PROSTHETIC LAB, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:J
Authorized Official - Last Name:OSTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-968-8555
Mailing Address - Street 1:748 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER GROVES
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1924
Mailing Address - Country:US
Mailing Address - Phone:314-968-8555
Mailing Address - Fax:
Practice Address - Street 1:12266 DEPAUL DR
Practice Address - Street 2:SUITE 120
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2514
Practice Address - Country:US
Practice Address - Phone:314-739-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-17
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
IL213.000099335E00000X
IL211.000024335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO621818608Medicaid