Provider Demographics
NPI:1992395255
Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity Type:Organization
Organization Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCK
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:616-502-6488
Mailing Address - Street 1:235 WEALTHY ST SE STE 1100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8400
Mailing Address - Fax:616-840-9602
Practice Address - Street 1:1717 STEPHENSON HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-2149
Practice Address - Country:US
Practice Address - Phone:248-680-2800
Practice Address - Fax:248-680-2804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier