Provider Demographics
NPI:1427234681
Name:PROSTHETIC LABORATORIES OF ROCHESTER, INC
Entity type:Organization
Organization Name:PROSTHETIC LABORATORIES OF ROCHESTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LACEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-536-6100
Mailing Address - Street 1:121 23RD AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-0998
Mailing Address - Country:US
Mailing Address - Phone:507-281-5250
Mailing Address - Fax:507-288-6928
Practice Address - Street 1:1300 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5103
Practice Address - Country:US
Practice Address - Phone:218-333-6966
Practice Address - Fax:218-333-6976
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GMS OF ROCHESTER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN286642000Medicaid
MN286642000Medicaid