Provider Demographics
NPI:1083895619
Name:ORTHOTICS SPECIALIST
Entity Type:Organization
Organization Name:ORTHOTICS SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-698-9377
Mailing Address - Street 1:4242 MEDICAL DR STE 2100
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5641
Mailing Address - Country:US
Mailing Address - Phone:210-698-9377
Mailing Address - Fax:210-698-2544
Practice Address - Street 1:ORTHOTICS SPECIALIST DBA HILL COUNTRY ORTHOTICS AND PRO
Practice Address - Street 2:6631 S ZARZAMORA ST
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78211
Practice Address - Country:US
Practice Address - Phone:210-977-0166
Practice Address - Fax:210-977-0168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-26
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101184335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX531770OtherBLUE CROSS BLUE SHIELD
TX171115204Medicaid
TX5771670001Medicare NSC