Provider Demographics
NPI: | 1952634982 |
---|---|
Name: | QUAD CITY PROSTHETIC INC |
Entity Type: | Organization |
Organization Name: | QUAD CITY PROSTHETIC INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | DONALD |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GOERTZEN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | CPO |
Authorized Official - Phone: | 309-676-2276 |
Mailing Address - Street 1: | 741 W MAIN ST |
Mailing Address - Street 2: | |
Mailing Address - City: | PEORIA |
Mailing Address - State: | IL |
Mailing Address - Zip Code: | 61606-1953 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 800-334-5705 |
Mailing Address - Fax: | 888-663-6322 |
Practice Address - Street 1: | 1222 SHOOTING PARK RD |
Practice Address - Street 2: | #104 |
Practice Address - City: | PERU |
Practice Address - State: | IL |
Practice Address - Zip Code: | 61354 |
Practice Address - Country: | US |
Practice Address - Phone: | 815-223-1781 |
Practice Address - Fax: | 815-223-1787 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-09-09 |
Last Update Date: | 2018-07-30 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 335E00000X | Suppliers | Prosthetic/Orthotic Supplier |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IL | =========001 | Medicaid | |
IL | =========001 | Medicaid |