1801130620 NPI number — GULF COAST PROSTHETICS

Table of content: (NPI 1801130620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801130620 NPI number — GULF COAST PROSTHETICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GULF COAST PROSTHETICS
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:
1801130620
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27350 BLUEBERRY HILL DR
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77385-8963
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-605-7466
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27350 BLUEBERRY HILL DR
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77385-8963
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-292-2255
Provider Business Practice Location Address Fax Number:
281-292-2299
Provider Enumeration Date:
11/16/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KMIEC
Authorized Official First Name:
TRACIE
Authorized Official Middle Name:
LEIGHANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-292-2255

Provider Taxonomy Codes

  • Taxonomy code: 224900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 332113502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com