1629043047 NPI number — PRECISION ORTHOTICS & PROSTHETICS, LLC

Table of content: (NPI 1629043047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629043047 NPI number — PRECISION ORTHOTICS & PROSTHETICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRECISION ORTHOTICS & 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:
POP 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:
1629043047
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 WOODMONT BLVD STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37205-5249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-864-8790
Provider Business Mailing Address Fax Number:
615-454-5352

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8915 S PECOS RD
Provider Second Line Business Practice Location Address:
SUITE 18A
Provider Business Practice Location Address City Name:
HENDERSON
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89074-7149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-243-7671
Provider Business Practice Location Address Fax Number:
702-259-7671
Provider Enumeration Date:
02/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GARDNER
Authorized Official First Name:
BRADFORD
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
615-864-8783

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100509314 . This is a "MEDICAID" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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