Provider Demographics
NPI:1487980405
Name:NORTH OTTAWA ORTHOTICS AND PROSTHETICS
Entity type:Organization
Organization Name:NORTH OTTAWA ORTHOTICS AND PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ORTHOTIST/ MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LUNSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:616-847-5365
Mailing Address - Street 1:1309 SHELDON RD
Mailing Address - Street 2:ORTHOTICS DEPT.
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-2404
Mailing Address - Country:US
Mailing Address - Phone:616-847-5365
Mailing Address - Fax:616-847-5294
Practice Address - Street 1:1309 SHELDON RD
Practice Address - Street 2:ORTHOTICS DEPT.
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-2404
Practice Address - Country:US
Practice Address - Phone:616-847-5365
Practice Address - Fax:616-847-5294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCO2816335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier