Provider Demographics
NPI:1851382691
Name:PROSTHETIC LABORATORIES OF ROCHESTER INC
Entity Type:Organization
Organization Name:PROSTHETIC LABORATORIES OF ROCHESTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-281-5250
Mailing Address - Street 1:2829 POST RD
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481-6416
Mailing Address - Country:US
Mailing Address - Phone:715-344-9328
Mailing Address - Fax:715-344-9385
Practice Address - Street 1:2829 POST RD
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-6416
Practice Address - Country:US
Practice Address - Phone:715-344-9328
Practice Address - Fax:715-344-9385
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GMS OF ROCHESTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-01
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41790800Medicaid
WI41790800Medicaid