Provider Demographics
NPI:1881193274
Name:ORTHOPEDIC REHABILITATION SUPPLY LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC REHABILITATION SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-310-8648
Mailing Address - Street 1:13 NORBLOOM AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1949
Mailing Address - Country:US
Mailing Address - Phone:309-310-8648
Mailing Address - Fax:
Practice Address - Street 1:13 NORBLOOM AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1949
Practice Address - Country:US
Practice Address - Phone:309-310-8648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-12
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOLC1242724332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies