Healthcare Provider Details

I. General information

NPI: 1689672750
Provider Name (Legal Business Name): PROSTHETIC DESIGN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 SCOTT AVE STE E
SAINT LOUIS MO
63103-3023
US

IV. Provider business mailing address

2665 SCOTT AVE STE E
SAINT LOUIS MO
63103-3023
US

V. Phone/Fax

Practice location:
  • Phone: 314-535-5359
  • Fax: 314-535-5488
Mailing address:
  • Phone: 314-535-5359
  • Fax: 314-535-5488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number17156319
License Number StateMO

VIII. Authorized Official

Name: MARK WILSON
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 314-535-5359