Provider Demographics
NPI:1831581164
Name:SUPERIOR PROSTHETICS AND ORTHOTICS
Entity type:Organization
Organization Name:SUPERIOR PROSTHETICS AND ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PENFOLD
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:906-231-2212
Mailing Address - Street 1:20075 THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MI
Mailing Address - Zip Code:49930
Mailing Address - Country:US
Mailing Address - Phone:906-523-5896
Mailing Address - Fax:906-523-5897
Practice Address - Street 1:20075 THIRD STREET
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930
Practice Address - Country:US
Practice Address - Phone:906-523-5896
Practice Address - Fax:906-523-5897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECPO01440335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier