1114219771 NPI number — INNOVATIVE PROSTHETIC CARE, INC.

Table of content: (NPI 1114219771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114219771 NPI number — INNOVATIVE PROSTHETIC CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INNOVATIVE PROSTHETIC CARE, 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:
6
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:
1114219771
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 650846
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75265-0846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
228-604-0818
Provider Business Mailing Address Fax Number:
228-604-0815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7530 HIGHWAY 57
Provider Second Line Business Practice Location Address:
STE I
Provider Business Practice Location Address City Name:
OCEAN SPRINGS
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39565-6512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
228-875-8354
Provider Business Practice Location Address Fax Number:
228-604-0815
Provider Enumeration Date:
05/13/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PRICE
Authorized Official First Name:
SHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF REIMBURSEMENT
Authorized Official Telephone Number:
503-493-8288

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , with the licence number: 07661/11.1 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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