Provider Demographics
NPI:1881182640
Name:WACO PROSTHETICS, INC.
Entity Type:Organization
Organization Name:WACO PROSTHETICS, INC.
Other - Org Name:INNOVATIVE PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-400-4363
Mailing Address - Street 1:201 COLONNADE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6174
Mailing Address - Country:US
Mailing Address - Phone:254-652-4898
Mailing Address - Fax:866-981-5223
Practice Address - Street 1:201 COLONNADE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-6174
Practice Address - Country:US
Practice Address - Phone:254-652-4898
Practice Address - Fax:866-981-5223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101602335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101602OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION