Provider Demographics
NPI:1184992190
Name:MIDWEST ORTHOTIC SERVICES LLC
Entity type:Organization
Organization Name:MIDWEST ORTHOTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-233-3352
Mailing Address - Street 1:17530 DUGDALE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1583
Mailing Address - Country:US
Mailing Address - Phone:574-233-3352
Mailing Address - Fax:
Practice Address - Street 1:611 E DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1464
Practice Address - Country:US
Practice Address - Phone:574-204-2416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier