Provider Demographics
NPI:1639124423
Name:MOUNTAIN STATE PROSTHETICS, LLC
Entity Type:Organization
Organization Name:MOUNTAIN STATE PROSTHETICS, LLC
Other - Org Name:MOUNTAIN STATE PROSTHETICS, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:P
Authorized Official - Last Name:HANSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:304-344-5593
Mailing Address - Street 1:216 BROOKS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1828
Mailing Address - Country:US
Mailing Address - Phone:304-344-5593
Mailing Address - Fax:304-344-5595
Practice Address - Street 1:216 BROOKS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1828
Practice Address - Country:US
Practice Address - Phone:304-344-5593
Practice Address - Fax:304-344-5595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2012-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0147696000Medicaid
WV0147696000Medicaid