Provider Demographics
NPI:1811418015
Name:PR ORTHOTICS & OT LLC
Entity Type:Organization
Organization Name:PR ORTHOTICS & OT LLC
Other - Org Name:CHICAGO PEDIATRIC ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ROGEL
Authorized Official - Suffix:
Authorized Official - Credentials:CO, OTR
Authorized Official - Phone:224-470-8550
Mailing Address - Street 1:4711 GOLF RD STE 1055
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1272
Mailing Address - Country:US
Mailing Address - Phone:224-470-8550
Mailing Address - Fax:224-470-8553
Practice Address - Street 1:4711 GOLF RD
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1224
Practice Address - Country:US
Practice Address - Phone:773-899-3885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1841338860Medicaid