Provider Demographics
NPI:1770718827
Name:NEW LIFE BRACE AND LIMB, LLC
Entity type:Organization
Organization Name:NEW LIFE BRACE AND LIMB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-316-5805
Mailing Address - Street 1:1666 W BAKER RD # B
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77521-2271
Mailing Address - Country:US
Mailing Address - Phone:281-427-8637
Mailing Address - Fax:281-427-8639
Practice Address - Street 1:1666 W BAKER RD # B
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-2271
Practice Address - Country:US
Practice Address - Phone:281-427-8637
Practice Address - Fax:281-427-8639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101294335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5712410002Medicare NSC