Healthcare Provider Details

I. General information

NPI: 1043114192
Provider Name (Legal Business Name): LDE CRANIAL PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19470 W HOPI DR
CASA GRANDE AZ
85122-8062
US

IV. Provider business mailing address

19470 W HOPI DR
CASA GRANDE AZ
85122-8062
US

V. Phone/Fax

Practice location:
  • Phone: 520-752-2400
  • Fax:
Mailing address:
  • Phone: 520-752-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL

VIII. Authorized Official

Name: LASHONDA ERVIN
Title or Position: OWNER
Credential:
Phone: 520-752-2400