Provider Demographics
NPI:1679567549
Name:HACKLEY ORTHOTICS & PROSTHETICS
Entity type:Organization
Organization Name:HACKLEY ORTHOTICS & PROSTHETICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:LUNSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:231-739-2217
Mailing Address - Street 1:1887 E SHERMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-1859
Mailing Address - Country:US
Mailing Address - Phone:231-739-2217
Mailing Address - Fax:231-737-6119
Practice Address - Street 1:1887 E SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-1859
Practice Address - Country:US
Practice Address - Phone:231-739-2217
Practice Address - Fax:231-737-6119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI530F10776OtherBCBS
MI530F10776OtherBCBS