Provider Demographics
NPI:1245268622
Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Entity type:Organization
Organization Name:MARY FREE BED ORTHOTICS AND PROSTHETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-356-1916
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-356-1916
Mailing Address - Fax:616-356-1868
Practice Address - Street 1:360 LAFAYETTE AVE SE
Practice Address - Street 2:SUITE 330
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4677
Practice Address - Country:US
Practice Address - Phone:616-356-1916
Practice Address - Fax:616-356-1868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI874438302Medicaid
MI530D105100OtherBLUE CROSS UPIN
MI530D105100OtherBLUE CROSS UPIN