1831705805 NPI number — FOURROUX PROSTHETICS, INC

Table of content: (NPI 1831705805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831705805 NPI number — FOURROUX PROSTHETICS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOURROUX 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:
1831705805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2743 BOB WALLACE AVE SW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35805-4103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-534-8672
Provider Business Mailing Address Fax Number:
800-963-5010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5453 N 59TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33610-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-374-6930
Provider Business Practice Location Address Fax Number:
800-963-5010
Provider Enumeration Date:
09/16/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WATSON
Authorized Official First Name:
W KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER, PRESIDENT
Authorized Official Telephone Number:
256-534-8672

Provider Taxonomy Codes

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

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

  • Identifier: 108805400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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