Provider Demographics
NPI:1467454959
Name:PROSTHETIC CENTER, INC.
Entity Type:Organization
Organization Name:PROSTHETIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:JUNTTONEN
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:517-372-7007
Mailing Address - Street 1:1200 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-1651
Mailing Address - Country:US
Mailing Address - Phone:517-372-7007
Mailing Address - Fax:517-372-0261
Practice Address - Street 1:1200 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-1651
Practice Address - Country:US
Practice Address - Phone:517-372-7007
Practice Address - Fax:517-372-0261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1904003Medicaid
MIP58725OtherBLUE CHOIC
MI520C303120OtherBLUE CROSS
MI650OtherNORTHWOOD
MIP58725OtherBLUE CARE NETWORK
MI52547OtherNORTHWOOD/NPN
MIP58725OtherBLUE CHOIC