Provider Demographics
NPI:1770535759
Name:INNOVATIVE PROSTHETIC DESIGNS LLC
Entity type:Organization
Organization Name:INNOVATIVE PROSTHETIC DESIGNS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:UNGARO
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:662-240-9700
Mailing Address - Street 1:PO BOX 689
Mailing Address - Street 2:
Mailing Address - City:AMORY
Mailing Address - State:MS
Mailing Address - Zip Code:38821-0689
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:523 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2225
Practice Address - Country:US
Practice Address - Phone:662-240-9700
Practice Address - Fax:662-240-9928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04057226Medicaid
MS04057226Medicaid