Provider Demographics
NPI:1508608167
Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity type:Organization
Organization Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Other - Org Name:<UNAVAIL>
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:616-617-0538
Mailing Address - Fax:
Practice Address - Street 1:550 MUNSON AVE STE M100A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-715-4755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-12
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier