1497945455 NPI number — PROSTHETIC CARE, LLC

Table of content: (NPI 1497945455)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497945455 NPI number — PROSTHETIC CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSTHETIC CARE, 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:
PROCARE PROSTHETICS AND ORTHOTICS
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:
1497945455
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4460 COMMERCE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUFORD
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30518-3489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-271-5581
Provider Business Mailing Address Fax Number:
770-271-5531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1445 OLD MCDONOUGH HWY SE
Provider Second Line Business Practice Location Address:
SUITE-A1
Provider Business Practice Location Address City Name:
CONYERS
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30094-5977
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-271-5581
Provider Business Practice Location Address Fax Number:
770-271-5531
Provider Enumeration Date:
07/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NEMANI
Authorized Official First Name:
PALLAVI
Authorized Official Middle Name:
CHINTAPALLI
Authorized Official Title or Position:
COMPLIANCE OFFICER
Authorized Official Telephone Number:
512-552-6311

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: 00678345A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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