Provider Demographics
NPI:1235195330
Name:SUPERIOR PROSTHETICS & ORTHOTICS LLC
Entity Type:Organization
Organization Name:SUPERIOR PROSTHETICS & ORTHOTICS LLC
Other - Org Name:BACILIO V. MORENO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSED PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:BACILIO
Authorized Official - Middle Name:V
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:SR
Authorized Official - Credentials:LP
Authorized Official - Phone:210-593-0953
Mailing Address - Street 1:7400 LOUIS PASTEUR
Mailing Address - Street 2:STE 202
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4542
Mailing Address - Country:US
Mailing Address - Phone:210-593-0953
Mailing Address - Fax:210-593-0954
Practice Address - Street 1:7400 LOUIS PASTEUR
Practice Address - Street 2:STE 202
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4542
Practice Address - Country:US
Practice Address - Phone:210-593-0953
Practice Address - Fax:210-593-0954
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX428335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0110058-01Medicaid
TX0110058-01Medicaid