Provider Demographics
NPI:1730724394
Name:PR ORTHOTICS & OT LLC
Entity type:Organization
Organization Name:PR ORTHOTICS & OT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ROGEL
Authorized Official - Suffix:
Authorized Official - Credentials:CO, LO, OTR/L
Authorized Official - Phone:224-470-8550
Mailing Address - Street 1:4711 GOLF RD STE 525
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1217
Mailing Address - Country:US
Mailing Address - Phone:224-470-8550
Mailing Address - Fax:224-470-8553
Practice Address - Street 1:4711 GOLF RD STE 1055
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1272
Practice Address - Country:US
Practice Address - Phone:224-470-8550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-07
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL374705580002Medicaid