Provider Demographics
NPI:1295959492
Name:PROSTHETICARE FORT WORTH LP
Entity type:Organization
Organization Name:PROSTHETICARE FORT WORTH LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-571-5631
Mailing Address - Street 1:7241 HAWKINS VIEW DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3921
Mailing Address - Country:US
Mailing Address - Phone:817-336-8293
Mailing Address - Fax:817-336-9017
Practice Address - Street 1:7241 HAWKINS VIEW DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3921
Practice Address - Country:US
Practice Address - Phone:817-336-8293
Practice Address - Fax:817-336-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10128335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX061254040761040000OtherCHAMPUS ID NUMBER
TX519839OtherBLUECROSSBLUESHIELD OF TX
TX824704OtherPCA HEALTH PLANS ID NUMBE
TX087392901Medicaid
TX62856OtherCSHCN ID NUMBER
TX8540817OtherAETNA ID NUMBER
TX80227OtherUNITED HEALTHCARE ID NUMB
TX10689OtherSECURE HORIZONS ID NUMBER
TX48393OtherAMERICAID AMERIGROUP ID
TX62856OtherCSHCN ID NUMBER