Healthcare Provider Details

I. General information

NPI: 1639498587
Provider Name (Legal Business Name): PREVAIL PROSTHETICS AND ORTHOTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2010
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6330 E 75TH ST SUITE 126
INDIANAPOLIS IN
46250-2777
US

IV. Provider business mailing address

7735 W JEFFERSON BLVD SUITE C
FORT WAYNE IN
46804-4135
US

V. Phone/Fax

Practice location:
  • Phone: 317-577-2273
  • Fax: 317-577-2279
Mailing address:
  • Phone: 260-483-5219
  • Fax: 260-484-2291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: CHRISTI HUDSON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 260-483-5219