Provider Demographics
NPI:1245310424
Name:ORTHOTIC & PROSTHETIC PROFESSIONAL CARE LLC
Entity type:Organization
Organization Name:ORTHOTIC & PROSTHETIC PROFESSIONAL CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:AMERICAN BOARD CERTI
Authorized Official - Phone:517-333-0304
Mailing Address - Street 1:PO BOX 80
Mailing Address - Street 2:
Mailing Address - City:GREGORY
Mailing Address - State:MI
Mailing Address - Zip Code:48137-0080
Mailing Address - Country:US
Mailing Address - Phone:517-333-0304
Mailing Address - Fax:517-333-7074
Practice Address - Street 1:200 WOODLAND PASS
Practice Address - Street 2:SUITE E
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823
Practice Address - Country:US
Practice Address - Phone:517-333-0304
Practice Address - Fax:517-333-7074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4503723Medicaid
MI4503723Medicaid