1184822793 NPI number — STEVEN G MCCULLOUGH AND DAVID W HOLT ORTHOTICS & PROSTHETICS, LLC

Table of content: MS. MONCEL A LOGAN-DEITZ PA-C (NPI 1891953527)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184822793 NPI number — STEVEN G MCCULLOUGH AND DAVID W HOLT ORTHOTICS & PROSTHETICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STEVEN G MCCULLOUGH AND DAVID W HOLT 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:
CUSTOM CARE ORTHOPEDIC BRACING AND 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:
1184822793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2020
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:
422 N GREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75601-6458
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-234-9300
Provider Business Practice Location Address Fax Number:
903-234-8704
Provider Enumeration Date:
07/05/2007

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 , with the licence number:  101171 , 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: 284080301 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 517688 . This is a "O&P" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 284080303 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6922550001 . This is a "DMEPOS MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".




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