Provider Demographics
NPI:1922057736
Name:ORTHOTICS GERIATRICS, INC.
Entity Type:Organization
Organization Name:ORTHOTICS GERIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN HAAFTEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-893-9238
Mailing Address - Street 1:2102 CLOVER CT
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-8353
Mailing Address - Country:US
Mailing Address - Phone:952-893-9238
Mailing Address - Fax:952-831-8405
Practice Address - Street 1:2102 CLOVER CT
Practice Address - Street 2:
Practice Address - City:CHANHASSEN
Practice Address - State:MN
Practice Address - Zip Code:55317-8353
Practice Address - Country:US
Practice Address - Phone:952-893-9238
Practice Address - Fax:952-831-8405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FM7G638GEOtherBLUECROSS BLUESHIELD OF M
1058180001Medicare ID - Type Unspecified