Provider Demographics
NPI:1609914860
Name:OPTECH ORTHOTICS & PROSTHETICS CORP
Entity Type:Organization
Organization Name:OPTECH ORTHOTICS & PROSTHETICS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ORTHOTIST PROSTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCNAB
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:815-932-8564
Mailing Address - Street 1:121 SPRINGFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435
Mailing Address - Country:US
Mailing Address - Phone:815-741-9700
Mailing Address - Fax:815-741-4701
Practice Address - Street 1:121 SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-741-9700
Practice Address - Fax:815-741-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
80543OtherNORTHWOOD UHC
04622011OtherBCBS
IL=========001Medicaid
04622011OtherBCBS