Provider Demographics
NPI:1033499744
Name:INNOVATIVE PROSTHETIC CARE TUPELO LLC
Entity Type:Organization
Organization Name:INNOVATIVE PROSTHETIC CARE TUPELO LLC
Other - Org Name:INNOVATIVE PROSTHETIC CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REIMBURSEMENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:S
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-493-8288
Mailing Address - Street 1:9034B CARL LEGETT RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-6234
Mailing Address - Country:US
Mailing Address - Phone:228-604-0818
Mailing Address - Fax:228-604-0815
Practice Address - Street 1:1714 N GLOSTER ST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-1216
Practice Address - Country:US
Practice Address - Phone:662-844-2202
Practice Address - Fax:601-510-1610
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-08-25
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS6622810001Medicare NSC