Provider Demographics
NPI:1568496479
Name:PETERMAN ORTHOTICS & PROSTHETICS LLC
Entity Type:Organization
Organization Name:PETERMAN ORTHOTICS & PROSTHETICS LLC
Other - Org Name:ADVANCED LIMB & BRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:G
Authorized Official - Last Name:KEMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-351-1775
Mailing Address - Street 1:2648 34TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410
Mailing Address - Country:US
Mailing Address - Phone:806-783-8388
Mailing Address - Fax:806-783-8956
Practice Address - Street 1:2648 34TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410
Practice Address - Country:US
Practice Address - Phone:806-783-8388
Practice Address - Fax:806-783-8956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX588335E00000X
TX215335E00000X
TX404335E00000X
TX591335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174985503Medicaid
TX5434060002Medicare NSC