Provider Demographics
NPI:1154964955
Name:NORTHERN ORTHOPEDIC LABORATORY INC.
Entity type:Organization
Organization Name:NORTHERN ORTHOPEDIC LABORATORY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:W
Authorized Official - Last Name:HOLMES
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:315-782-9079
Mailing Address - Street 1:1012 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4337
Mailing Address - Country:US
Mailing Address - Phone:315-782-9079
Mailing Address - Fax:
Practice Address - Street 1:6604 STATE HIGHWAY 56 APT 6
Practice Address - Street 2:
Practice Address - City:POTSDAM
Practice Address - State:NY
Practice Address - Zip Code:13676-3546
Practice Address - Country:US
Practice Address - Phone:315-782-9079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier