Provider Demographics
NPI:1174767024
Name:MISSOULA ORTHOTICS & PROSTHETICS LABORATORY INC
Entity type:Organization
Organization Name:MISSOULA ORTHOTICS & PROSTHETICS LABORATORY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN, CFM
Authorized Official - Phone:406-549-0921
Mailing Address - Street 1:120 SOUTH AVE W
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-8116
Mailing Address - Country:US
Mailing Address - Phone:406-549-0921
Mailing Address - Fax:
Practice Address - Street 1:400 W MAIN ST
Practice Address - Street 2:SUITE #203
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-2439
Practice Address - Country:US
Practice Address - Phone:406-549-0921
Practice Address - Fax:406-549-6864
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSOULA ORTHOTICS & PROSTHETICS LABORATORY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier