1588650337 NPI number — NEW LIFE PROSTHETICS AND ORTHOTICS

Table of content: KEVIN ANTHONY SMITH M.D. (NPI 1093852642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588650337 NPI number — NEW LIFE PROSTHETICS AND ORTHOTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW LIFE PROSTHETICS AND ORTHOTICS
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:
1588650337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2013 WELLS BRANCH PKWY
Provider Second Line Business Mailing Address:
STE 207
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78728-6900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-252-7177
Provider Business Mailing Address Fax Number:
512-252-7156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2013 WELLS BRANCH PKWY
Provider Second Line Business Practice Location Address:
STE 207
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78728-6900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-252-7177
Provider Business Practice Location Address Fax Number:
512-252-7156
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
ATHA
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
BOWDEN
Authorized Official Title or Position:
ORTHOTIST PROSTHETIST MANAGER
Authorized Official Telephone Number:
512-252-7177

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  2 , 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: 143350002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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