Provider Demographics
NPI:1720397490
Name:ACCESS PROSTHETICS LLC
Entity Type:Organization
Organization Name:ACCESS PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENTON
Authorized Official - Middle Name:M
Authorized Official - Last Name:WATZKA
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:920-680-0271
Mailing Address - Street 1:2020 RIVERSIDE DR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2300
Mailing Address - Country:US
Mailing Address - Phone:920-471-1451
Mailing Address - Fax:920-569-2939
Practice Address - Street 1:2020 RIVERSIDE DR
Practice Address - Street 2:3RD FLOOR
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2300
Practice Address - Country:US
Practice Address - Phone:920-471-1451
Practice Address - Fax:920-569-2939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6486040001Medicare NSC