MEDICARE: PROSTHETIC CENTER OF EXCELLENCE, A NEVADA CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457348823
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROSTHETIC CENTER OF EXCELLENCE, A NEVADA CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 650846
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75265-0846
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2047 W CHARLESTON BLVD STE 100
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-2251
Country	:	US
Telephone Number	:	702-384-1410
Fax Number	:	702-384-0479

Authorized Official
Title or Position	:	PROVIDER CONTRACT ANALYST III
Name	:	GRACE ANGELINE
Credential	:
Telephone Number	:	714-961-2102

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	11/14/2023

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