1245214568 NPI number — GASTON AVENUE PROSTHETICS, LLC

Table of content: (NPI 1245214568)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245214568 NPI number — GASTON AVENUE PROSTHETICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTON AVENUE PROSTHETICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
M-POWER PROSTHETICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245214568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9900 N CENTRAL EXPY
Provider Second Line Business Mailing Address:
#205
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75231-4395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-265-5060
Provider Business Mailing Address Fax Number:
214-265-9055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9900 N CENTRAL EXPY
Provider Second Line Business Practice Location Address:
#205
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231-4395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-265-5060
Provider Business Practice Location Address Fax Number:
214-265-9055
Provider Enumeration Date:
11/30/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MILLER-MEHARY
Authorized Official First Name:
CATHERINE
Authorized Official Middle Name:
AMY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
214-265-5060

Provider Taxonomy Codes

  • Taxonomy code: 261QA0900X , with the licence number:  101185 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , with the licence number: 101185 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 532218 . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1791246-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".