Provider Demographics
NPI:1639498587
Name:PREVAIL PROSTHETICS AND ORTHOTICS
Entity Type:Organization
Organization Name:PREVAIL PROSTHETICS AND ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-483-5219
Mailing Address - Street 1:7735 W JEFFERSON BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4135
Mailing Address - Country:US
Mailing Address - Phone:260-483-5219
Mailing Address - Fax:260-484-2291
Practice Address - Street 1:6330 E 75TH ST
Practice Address - Street 2:SUITE 126
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2777
Practice Address - Country:US
Practice Address - Phone:317-577-2273
Practice Address - Fax:317-577-2279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-18
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0192680007Medicare NSC