Provider Demographics
NPI:1154721785
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
Entity type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:612-596-6205
Mailing Address - Street 1:PO BOX 947109
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7109
Mailing Address - Country:US
Mailing Address - Phone:813-367-2876
Mailing Address - Fax:813-518-7659
Practice Address - Street 1:215 RADIO DR STE 100
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-5817
Practice Address - Country:US
Practice Address - Phone:612-593-6205
Practice Address - Fax:612-335-5396
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - MIDWEST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-02
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier