Provider Demographics
NPI:1427231612
Name:NEW LIFE PROSTHETICS CORPORATION
Entity Type:Organization
Organization Name:NEW LIFE PROSTHETICS CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PROSTHETIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:TERRY
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:423-949-8620
Mailing Address - Street 1:87 NELMS RD
Mailing Address - Street 2:
Mailing Address - City:GRAYSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37338-4632
Mailing Address - Country:US
Mailing Address - Phone:423-949-8620
Mailing Address - Fax:
Practice Address - Street 1:87 NELMS RD
Practice Address - Street 2:
Practice Address - City:GRAYSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37338-4632
Practice Address - Country:US
Practice Address - Phone:423-949-8620
Practice Address - Fax:423-949-9217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO0000000083335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN0100OtherAMERICHOICE/TENNCARE
TN1454290Medicaid
GA198356168AMedicaid
TN4067689OtherBLUE CROSS BLUE SHIELD TN
GA198356168AMedicaid