Provider Demographics
NPI:1790873685
Name:LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS, INC.
Entity Type:Organization
Organization Name:LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SAUNDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-397-2165
Mailing Address - Street 1:PO BOX 24128
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-4128
Mailing Address - Country:US
Mailing Address - Phone:336-397-2165
Mailing Address - Fax:336-397-2167
Practice Address - Street 1:1601 HIGHWAY 59 LOOP N
Practice Address - Street 2:STE 500
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-6685
Practice Address - Country:US
Practice Address - Phone:936-327-2115
Practice Address - Fax:936-327-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101505335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207098901Medicaid
TX519208OtherBCBS
TX207098901Medicaid