Provider Demographics
NPI:1629214572
Name:PROSTHETIC AND ORTHOTIC CARE LLC
Entity Type:Organization
Organization Name:PROSTHETIC AND ORTHOTIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-775-2041
Mailing Address - Street 1:1084 OLD DES PERES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1865
Mailing Address - Country:US
Mailing Address - Phone:314-775-2041
Mailing Address - Fax:
Practice Address - Street 1:1479 HIGHWAY 61
Practice Address - Street 2:SUITE D
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4109
Practice Address - Country:US
Practice Address - Phone:636-232-2982
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROSTHETIC AND ORTHOTIC CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-12-24
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO625748603Medicaid
MO626167407Medicaid
IL=========001Medicaid
4398160003Medicare NSC
MO625748603Medicaid
MO626167407Medicaid