Provider Demographics
NPI:1780624148
Name:PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC.
Entity type:Organization
Organization Name:PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:903-592-6574
Mailing Address - Street 1:1028 E IDEL ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2024
Mailing Address - Country:US
Mailing Address - Phone:903-592-6574
Mailing Address - Fax:903-595-3862
Practice Address - Street 1:1028 E IDEL ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2024
Practice Address - Country:US
Practice Address - Phone:903-592-6574
Practice Address - Fax:903-595-3862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000086335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079440601OtherCSHCN-ORTHOTICS
TX079439801OtherCSHCN-PROTHETICS
515809OtherBCBS-TEXAS
TX087369701Medicaid
TX079439801OtherCSHCN-PROTHETICS