Provider Demographics
NPI:1558786905
Name:FOURROUX PROSTHETICS, INC
Entity Type:Organization
Organization Name:FOURROUX PROSTHETICS, INC
Other - Org Name:FOURROUX PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:256-534-8672
Mailing Address - Street 1:2743 BOB WALLACE AVE SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805-4103
Mailing Address - Country:US
Mailing Address - Phone:256-534-8672
Mailing Address - Fax:800-963-5010
Practice Address - Street 1:5209 LINBAR DR STE 603
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37211-1027
Practice Address - Country:US
Practice Address - Phone:615-471-4383
Practice Address - Fax:800-963-5010
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOURROUX PROSTHETICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-21
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6192613OtherBCBS OF TENNESSEE
TNQ050007Medicaid