1790873685 NPI number — LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS, INC.

Table of content: (NPI 1790873685)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790873685 NPI number — LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS, INC.
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:
1790873685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 24128
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27114-4128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-397-2165
Provider Business Mailing Address Fax Number:
336-397-2167

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1601 HIGHWAY 59 LOOP N
Provider Second Line Business Practice Location Address:
STE 500
Provider Business Practice Location Address City Name:
LIVINGSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77351-6685
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-327-2115
Provider Business Practice Location Address Fax Number:
936-327-2116
Provider Enumeration Date:
10/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAUNDERS
Authorized Official First Name:
JAN
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
336-397-2165

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  101505 , 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: 207098901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 519208 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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