Provider Demographics
NPI:1437187804
Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Other - Org Name:MARY FREE BED BRACE AND CORSET SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-840-8433
Mailing Address - Street 1:12662 RILEY ST
Mailing Address - Street 2:STE 140
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8023
Mailing Address - Country:US
Mailing Address - Phone:616-840-8433
Mailing Address - Fax:616-840-9504
Practice Address - Street 1:12662 RILEY ST
Practice Address - Street 2:SUITE 140
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8023
Practice Address - Country:US
Practice Address - Phone:616-840-8433
Practice Address - Fax:616-840-9504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI853484356Medicaid
MI530D105100OtherBLUE CROSS UPIN
MI0402260006Medicare NSC