Provider Demographics
NPI:1720023724
Name:GREAT LAKES ORTHOTICS & PROSTHETICS INC.
Entity Type:Organization
Organization Name:GREAT LAKES ORTHOTICS & PROSTHETICS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:ALGER
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:920-968-2240
Mailing Address - Street 1:3950 EVERGREEN CT STE A
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8903
Mailing Address - Country:US
Mailing Address - Phone:920-968-2240
Mailing Address - Fax:920-968-2241
Practice Address - Street 1:3950 EVERGREEN CT STE A
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8903
Practice Address - Country:US
Practice Address - Phone:920-968-2240
Practice Address - Fax:920-968-2241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41792000Medicaid
WI5718490001Medicare NSC