Provider Demographics
NPI:1801907217
Name:PROSTHETIC ORTHOTIC CENTER LTE
Entity type:Organization
Organization Name:PROSTHETIC ORTHOTIC CENTER LTE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ V.P.
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:LOTZ
Authorized Official - Suffix:
Authorized Official - Credentials:CFM, RFM
Authorized Official - Phone:715-845-2800
Mailing Address - Street 1:1108 S 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-5709
Mailing Address - Country:US
Mailing Address - Phone:715-845-2800
Mailing Address - Fax:715-845-2855
Practice Address - Street 1:1108 S 17TH AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-5709
Practice Address - Country:US
Practice Address - Phone:715-845-2800
Practice Address - Fax:715-845-2855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41782800Medicaid
WI41782800Medicaid