Provider Demographics
NPI:1700203510
Name:DUPAGE PROSTHETIC-ORTHOTIC SERVICES
Entity type:Organization
Organization Name:DUPAGE PROSTHETIC-ORTHOTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROONEY
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:630-261-9317
Mailing Address - Street 1:121 E ROOSEVELT RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4561
Mailing Address - Country:US
Mailing Address - Phone:630-261-9317
Mailing Address - Fax:
Practice Address - Street 1:410 W ICE LAKE RD
Practice Address - Street 2:
Practice Address - City:IRON RIVER
Practice Address - State:MI
Practice Address - Zip Code:49935-8417
Practice Address - Country:US
Practice Address - Phone:630-261-9317
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL211.000188335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1740466101Medicaid