Provider Demographics
NPI:1700832227
Name:PROSTHETIC & ORTHOTIC GROUP OF NORTHERN CO., LLC
Entity Type:Organization
Organization Name:PROSTHETIC & ORTHOTIC GROUP OF NORTHERN CO., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-595-6445
Mailing Address - Street 1:2290 E PROSPECT RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9768
Mailing Address - Country:US
Mailing Address - Phone:970-416-9357
Mailing Address - Fax:970-416-9359
Practice Address - Street 1:2290 E PROSPECT RD
Practice Address - Street 2:SUITE 2
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9768
Practice Address - Country:US
Practice Address - Phone:970-416-9357
Practice Address - Fax:970-416-9359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO46150544Medicaid
WY117338300Medicaid
WY117338300Medicaid