Provider Demographics
NPI:1255841482
Name:PROSTHETIC ONE
Entity Type:Organization
Organization Name:PROSTHETIC ONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:T
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:901-795-1776
Mailing Address - Street 1:3050 S CENTER ST STE 120
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-2154
Mailing Address - Country:US
Mailing Address - Phone:682-323-5921
Mailing Address - Fax:682-323-5974
Practice Address - Street 1:3050 S CENTER ST STE 120
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-2154
Practice Address - Country:US
Practice Address - Phone:682-323-5921
Practice Address - Fax:682-323-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-02
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101575335E00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX373710802Medicaid
TX373710801Medicaid