1750679064 NPI number — PROSTHETIC CARE OF ANDERSON, LLC

Table of content: (NPI 1750679064)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750679064 NPI number — PROSTHETIC CARE OF ANDERSON, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROSTHETIC CARE OF ANDERSON, 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:
Provider Other Organization Name Type Code:
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:
1750679064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18022 COWAN
Provider Second Line Business Mailing Address:
SUITE 285
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92614-6806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
949-863-1951
Provider Business Mailing Address Fax Number:
949-863-1419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 COOK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROYSTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30662-3933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-245-6212
Provider Business Practice Location Address Fax Number:
706-245-6262
Provider Enumeration Date:
07/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HAMONTREE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
949-863-1951

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  90 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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