Provider Demographics
NPI:1700936234
Name:KOEBERS PROSTHETIC & ORTHOTIC LAB INC.
Entity type:Organization
Organization Name:KOEBERS PROSTHETIC & ORTHOTIC LAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GOERTZEN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:309-676-2276
Mailing Address - Street 1:741 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-1953
Mailing Address - Country:US
Mailing Address - Phone:800-334-5705
Mailing Address - Fax:888-663-6322
Practice Address - Street 1:3834 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618
Practice Address - Country:US
Practice Address - Phone:773-539-7333
Practice Address - Fax:773-539-5535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01680020OtherBLUE CROSS BLUE SHIELD
IL=========001Medicaid
IL0470630001Medicare NSC