Provider Demographics
NPI:1952847592
Name:PERSONALIZED PROSTHETICS
Entity Type:Organization
Organization Name:PERSONALIZED PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRADER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, CCA
Authorized Official - Phone:210-802-8313
Mailing Address - Street 1:628 S PRESA ST # 5
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78210-1054
Mailing Address - Country:US
Mailing Address - Phone:210-802-8313
Mailing Address - Fax:
Practice Address - Street 1:628 S PRESA ST # 5
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78210-1054
Practice Address - Country:US
Practice Address - Phone:210-802-8313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX377522301Medicaid