Provider Demographics
NPI:1295085181
Name:SELECT ORTHOPEDIC SUPPLY
Entity type:Organization
Organization Name:SELECT ORTHOPEDIC SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PEDORTHIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:OSTROWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:C-PED
Authorized Official - Phone:269-629-4853
Mailing Address - Street 1:8589 GULL RD, STE 2
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49083
Mailing Address - Country:US
Mailing Address - Phone:269-629-4853
Mailing Address - Fax:269-629-5085
Practice Address - Street 1:8589 GULL RD, STE 2
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:MI
Practice Address - Zip Code:49083
Practice Address - Country:US
Practice Address - Phone:269-629-4853
Practice Address - Fax:269-629-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICPED3724335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier