Provider Demographics
NPI:1619302163
Name:NORTHERN ORTHOTICS AND PROSTHETIC SERVICES CORPORATION
Entity Type:Organization
Organization Name:NORTHERN ORTHOTICS AND PROSTHETIC SERVICES CORPORATION
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:J
Authorized Official - Last Name:FRANCISCO
Authorized Official - Suffix:
Authorized Official - Credentials:BS,CO
Authorized Official - Phone:218-249-6250
Mailing Address - Street 1:8501 FALCON ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55808-1533
Mailing Address - Country:US
Mailing Address - Phone:218-249-6250
Mailing Address - Fax:218-249-6255
Practice Address - Street 1:2724 STEWART AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4153
Practice Address - Country:US
Practice Address - Phone:715-298-4490
Practice Address - Fax:715-298-4492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment