Provider Demographics
NPI:1710308200
Name:GREAT LAKES ORTHOTICS AND MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:GREAT LAKES ORTHOTICS AND MEDICAL SUPPLY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUGGY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-227-0346
Mailing Address - Street 1:8633 W GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4362
Mailing Address - Country:US
Mailing Address - Phone:262-361-4389
Mailing Address - Fax:
Practice Address - Street 1:8633 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4362
Practice Address - Country:US
Practice Address - Phone:262-361-4389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-30
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier