Provider Demographics
NPI:1194919167
Name:OPTECH ORTHOTICS & PROSTHETICS CORP
Entity type:Organization
Organization Name:OPTECH ORTHOTICS & PROSTHETICS CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED ORTHOTIST PROSTHOTIST PRE
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCNAB
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:815-932-8564
Mailing Address - Street 1:111 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450
Mailing Address - Country:US
Mailing Address - Phone:815-741-9700
Mailing Address - Fax:815-741-4701
Practice Address - Street 1:111 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450
Practice Address - Country:US
Practice Address - Phone:815-741-9700
Practice Address - Fax:815-741-4701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL80543OtherNORTHWOOD UHC
IL04622011OtherBCBS
IL=========001Medicaid
1245500002Medicare NSC