Provider Demographics
NPI:1073655858
Name:PROSTHETIC LABORATORIES LABORATORIES OF ROCHESTER
Entity type:Organization
Organization Name:PROSTHETIC LABORATORIES LABORATORIES OF ROCHESTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-281-5250
Mailing Address - Street 1:620 W 18TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57104-4844
Mailing Address - Country:US
Mailing Address - Phone:605-332-1878
Mailing Address - Fax:605-334-4045
Practice Address - Street 1:620 W 18TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57104-4844
Practice Address - Country:US
Practice Address - Phone:605-332-1878
Practice Address - Fax:605-334-4045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GMS OF ROCHESTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0146110013Medicare NSC