Provider Demographics
NPI:1538315791
Name:BOSSIER CITY PROSTHETIC & ORTHOTICS
Entity Type:Organization
Organization Name:BOSSIER CITY PROSTHETIC & ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:318-746-5000
Mailing Address - Street 1:4859 SHED RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5493
Mailing Address - Country:US
Mailing Address - Phone:318-746-5000
Mailing Address - Fax:318-746-4000
Practice Address - Street 1:4859 SHED ROAD STE 200
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111
Practice Address - Country:US
Practice Address - Phone:318-746-5000
Practice Address - Fax:318-746-4000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier