Provider Demographics
NPI:1114176138
Name:PROSTHETIC DESIGN INC
Entity Type:Organization
Organization Name:PROSTHETIC DESIGN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/V.P.
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-535-5359
Mailing Address - Street 1:PO BOX 444
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63022
Mailing Address - Country:US
Mailing Address - Phone:314-535-5359
Mailing Address - Fax:314-535-5488
Practice Address - Street 1:142 JUNGERMANN ROAD
Practice Address - Street 2:
Practice Address - City:ST. PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376
Practice Address - Country:US
Practice Address - Phone:314-535-5359
Practice Address - Fax:314-535-5488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-15
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO17156319335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO624794301Medicaid
IL=========001Medicaid