Provider Demographics
NPI:1154894046
Name:LAKER PROSTHETICS
Entity type:Organization
Organization Name:LAKER PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:616-490-8564
Mailing Address - Street 1:5181 PLAINFIELD AVE NE
Mailing Address - Street 2:SUITE D
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525
Mailing Address - Country:US
Mailing Address - Phone:616-490-8564
Mailing Address - Fax:616-469-2962
Practice Address - Street 1:5181 PLAINFIELD AVE NE
Practice Address - Street 2:SUITE D
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525
Practice Address - Country:US
Practice Address - Phone:616-490-8564
Practice Address - Fax:616-469-2962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-03
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP03634OtherABC