Provider Demographics
NPI:1801130620
Name:GULF COAST PROSTHETICS
Entity type:Organization
Organization Name:GULF COAST PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:LEIGHANN
Authorized Official - Last Name:KMIEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-292-2255
Mailing Address - Street 1:27350 BLUEBERRY HILL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77385-8963
Mailing Address - Country:US
Mailing Address - Phone:832-605-7466
Mailing Address - Fax:
Practice Address - Street 1:27350 BLUEBERRY HILL DR
Practice Address - Street 2:SUITE 1
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77385-8963
Practice Address - Country:US
Practice Address - Phone:281-292-2255
Practice Address - Fax:281-292-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-16
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy FitterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX332113502Medicaid