Provider Demographics
NPI:1760835938
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, ORTHOTICS AND PROSTHETICS
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:CRAGGS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO, LPO
Authorized Official - Phone:773-385-5848
Mailing Address - Street 1:PO BOX 865109
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-5109
Mailing Address - Country:US
Mailing Address - Phone:844-602-3960
Mailing Address - Fax:813-518-7659
Practice Address - Street 1:2211 N OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707-3351
Practice Address - Country:US
Practice Address - Phone:773-385-5848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier