Provider Demographics
NPI:1063517241
Name:METROPOLITAN ORTHOTIC LABORATORY, INC.
Entity type:Organization
Organization Name:METROPOLITAN ORTHOTIC LABORATORY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBBY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-341-3660
Mailing Address - Street 1:817 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-1145
Mailing Address - Country:US
Mailing Address - Phone:612-341-3660
Mailing Address - Fax:612-341-3664
Practice Address - Street 1:817 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-1145
Practice Address - Country:US
Practice Address - Phone:612-341-3660
Practice Address - Fax:612-341-3664
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN848363900Medicaid
MN58243MEOtherBCBS MN
MN0459920001Medicare NSC