Provider Demographics
NPI:1508048984
Name:EAST TEXAS PROSTHETIC-ORTHOTIC CARE
Entity Type:Organization
Organization Name:EAST TEXAS PROSTHETIC-ORTHOTIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:III
Authorized Official - Credentials:CPO
Authorized Official - Phone:903-236-4488
Mailing Address - Street 1:812 N 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5413
Mailing Address - Country:US
Mailing Address - Phone:903-236-4488
Mailing Address - Fax:903-236-4607
Practice Address - Street 1:812 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5413
Practice Address - Country:US
Practice Address - Phone:903-236-4488
Practice Address - Fax:903-236-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000020335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX519698OtherBLUE CROSS BLUE SHIELD
TX010236001Medicaid
TX519698OtherBLUE CROSS BLUE SHIELD