Provider Demographics
NPI:1245214568
Name:GASTON AVENUE PROSTHETICS, LLC
Entity Type:Organization
Organization Name:GASTON AVENUE PROSTHETICS, LLC
Other - Org Name:M-POWER PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:AMY
Authorized Official - Last Name:MILLER-MEHARY
Authorized Official - Suffix:
Authorized Official - Credentials:CP,LP,BOCO
Authorized Official - Phone:214-265-5060
Mailing Address - Street 1:9900 N CENTRAL EXPY
Mailing Address - Street 2:#205
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4395
Mailing Address - Country:US
Mailing Address - Phone:214-265-5060
Mailing Address - Fax:214-265-9055
Practice Address - Street 1:9900 N CENTRAL EXPY
Practice Address - Street 2:#205
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4395
Practice Address - Country:US
Practice Address - Phone:214-265-5060
Practice Address - Fax:214-265-9055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101185261QA0900X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No261QA0900XAmbulatory Health Care FacilitiesClinic/CenterAmputee
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX532218OtherBLUE CROSS BLUE SHIELD TX
TX1791246-01Medicaid
TX1791246-01Medicaid