Provider Demographics
NPI:1780666081
Name:BASIN ORTHOTIC & PROSTHETIC CENTER PLLC
Entity Type:Organization
Organization Name:BASIN ORTHOTIC & PROSTHETIC CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:C
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPO,CPO,BOC-OP
Authorized Official - Phone:432-337-8880
Mailing Address - Street 1:623 N SAM HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4434
Mailing Address - Country:US
Mailing Address - Phone:432-337-8880
Mailing Address - Fax:432-337-8887
Practice Address - Street 1:623 N SAM HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4434
Practice Address - Country:US
Practice Address - Phone:432-337-8880
Practice Address - Fax:432-337-8887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2016-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101080335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149744804Medicaid
TX149744806Medicaid
TX4395990001Medicare NSC
TX1497448 03Medicaid
TX1497448 01Medicaid