Provider Demographics
NPI:1790787216
Name:LAND OF LAKES ORTHOTICS & PROSTHETICS
Entity Type:Organization
Organization Name:LAND OF LAKES ORTHOTICS & PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROSTHETIST ORTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:V
Authorized Official - Last Name:POULSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:952-745-3004
Mailing Address - Street 1:14395 23RD AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4704
Mailing Address - Country:US
Mailing Address - Phone:952-745-3004
Mailing Address - Fax:952-745-3010
Practice Address - Street 1:14395 23RD AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-4704
Practice Address - Country:US
Practice Address - Phone:952-745-3004
Practice Address - Fax:952-745-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN8200254OtherMEDICA
MN562317100Medicaid
MN121144OtherUCARE
MN562317100Medicaid