Healthcare Provider Details

I. General information

NPI: 1104613975
Provider Name (Legal Business Name): XTREME PROSTHETICS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 HIBBARD ST STE 1
PIKEVILLE KY
41501-4792
US

IV. Provider business mailing address

102 WOODMONT BLVD STE 400
NASHVILLE TN
37205-5217
US

V. Phone/Fax

Practice location:
  • Phone: 606-506-1250
  • Fax:
Mailing address:
  • Phone: 615-864-8790
  • Fax: 615-864-8790

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: BRADFORD GARDNER
Title or Position: COO
Credential:
Phone: 615-864-8783