Provider Demographics
NPI:1588650337
Name:NEW LIFE PROSTHETICS AND ORTHOTICS
Entity Type:Organization
Organization Name:NEW LIFE PROSTHETICS AND ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOTIST PROSTHETIST MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:BOWDEN
Authorized Official - Last Name:ATHA
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:512-252-7177
Mailing Address - Street 1:2013 WELLS BRANCH PKWY
Mailing Address - Street 2:STE 207
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-6900
Mailing Address - Country:US
Mailing Address - Phone:512-252-7177
Mailing Address - Fax:512-252-7156
Practice Address - Street 1:2013 WELLS BRANCH PKWY
Practice Address - Street 2:STE 207
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78728-6900
Practice Address - Country:US
Practice Address - Phone:512-252-7177
Practice Address - Fax:512-252-7156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143350002Medicaid
4006220001Medicare ID - Type Unspecified