Provider Demographics
NPI:1659851699
Name:PROSTHETICS ADVANCEMENT LAB, LLC
Entity Type:Organization
Organization Name:PROSTHETICS ADVANCEMENT LAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHAO
Authorized Official - Suffix:
Authorized Official - Credentials:BCO, CCA
Authorized Official - Phone:702-609-9203
Mailing Address - Street 1:3199 E WARM SPRINGS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3150
Mailing Address - Country:US
Mailing Address - Phone:702-207-9500
Mailing Address - Fax:702-852-0492
Practice Address - Street 1:3199 E WARM SPRINGS RD STE 300
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3150
Practice Address - Country:US
Practice Address - Phone:702-207-9500
Practice Address - Fax:702-852-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Multi-Specialty
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1972002632Medicaid