Basic Information
| Provider Information | |||||||||
| NPI: | 1538163183 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC PROSTHETICS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12926 WILLOW CHASE DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770705641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818971108 | ||||||||
| FaxNumber: | 2818978462 | ||||||||
| Practice Location | |||||||||
| Address1: | 12926 WILLOW CHASE DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770705641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818971108 | ||||||||
| FaxNumber: | 2818978462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2005 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | PUTBACK-BEAN | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2818971108 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | 101134 | TX | N | Suppliers | Prosthetic/Orthotic Supplier | 225000000X | 101134 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
ID Information
| ID | Type | State | Issuer | Description | 531649 | 01 | TX | BLUE CROSS BLUE SHIEL | OTHER | 1670572-01 | 05 | TX | MEDICAID |