Form Orthotics & Prosthetics, PLLC

Primary specialty

Prosthetic/Orthotic SupplierTaxonomy code 335E00000X

Legal business name

FORM ORTHOTICS & PROSTHETICS, PLLC

Practice address

4921 E State St Lowr Level
Rockford, IL 61108-2275

Phone

(402) 212-7878

NPI assigned

Jun 4, 2026

Last updated

Jun 4, 2026By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Micah Alford, L/CPO

Title

Founder

Phone

(402) 212-7878

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1780531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1780531200000",
    "number": "1740113422",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4921 E STATE ST LOWR LEVEL",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611082275"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4921 E STATE ST LOWR LEVEL",
            "city": "ROCKFORD",
            "state": "IL",
            "postal_code": "611082275",
            "telephone_number": "402-212-7878"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORM ORTHOTICS & PROSTHETICS, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2026-06-04",
        "last_updated": "2026-06-04",
        "certification_date": "2026-06-04",
        "status": "A",
        "authorized_official_last_name": "ALFORD",
        "authorized_official_first_name": "MICAH",
        "authorized_official_title_or_position": "FOUNDER",
        "authorized_official_telephone_number": "402-212-7878",
        "authorized_official_credential": "L/CPO"
    },
    "taxonomies": [
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Prosthetic/Orthotic Supplier in Rockford, IL
• Providers in Rockford, IL by specialty
• Prosthetic/Orthotic Supplier in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 4, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.