Provider Demographics
NPI:1649386293
Name:ORTHOTIC & PROSTHETIC HEALTH
Entity Type:Organization
Organization Name:ORTHOTIC & PROSTHETIC HEALTH
Other - Org Name:O & P HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:218-847-6767
Mailing Address - Street 1:810 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:SD
Mailing Address - Zip Code:57201
Mailing Address - Country:US
Mailing Address - Phone:605-886-3272
Mailing Address - Fax:
Practice Address - Street 1:214 FRONT ST W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3020
Practice Address - Country:US
Practice Address - Phone:218-847-6767
Practice Address - Fax:218-847-7676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCO1105335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN431G30ROtherBCBS
SD9162720Medicaid
MN5026500002OtherMEDICINE B
MN58576100Medicaid
MN431G30ROtherBCBS