Provider Demographics
NPI:1831371343
Name:PROSTHETIC AND ORTHOTIC PROFESSIONAL SERVICES, LLC
Entity type:Organization
Organization Name:PROSTHETIC AND ORTHOTIC PROFESSIONAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:PERTEATE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CPO LPO
Authorized Official - Phone:713-818-7599
Mailing Address - Street 1:PO BOX 2382
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77487-2382
Mailing Address - Country:US
Mailing Address - Phone:713-818-7599
Mailing Address - Fax:713-776-8259
Practice Address - Street 1:8449 W BELLFORT ST
Practice Address - Street 2:380
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77071-2248
Practice Address - Country:US
Practice Address - Phone:713-818-7599
Practice Address - Fax:713-776-8259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101205335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183391502Medicaid
5730870001Medicare NSC
TX5730870001Medicare NSC