Provider Demographics
NPI:1831137280
Name:ADVANCED ORTHOPEDIC LABORATORY INC
Entity Type:Organization
Organization Name:ADVANCED ORTHOPEDIC LABORATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TREASURER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:C
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-557-2323
Mailing Address - Street 1:24395 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3118
Mailing Address - Country:US
Mailing Address - Phone:248-557-2323
Mailing Address - Fax:248-557-3639
Practice Address - Street 1:24395 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3118
Practice Address - Country:US
Practice Address - Phone:248-557-2323
Practice Address - Fax:248-557-3639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0578050001Medicare ID - Type Unspecified