Healthcare Provider Details

I. General information

NPI: 1114176138
Provider Name (Legal Business Name): PROSTHETIC DESIGN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 JUNGERMANN ROAD
ST. PETERS MO
63376
US

IV. Provider business mailing address

PO BOX 444
BALLWIN MO
63022
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: MRS. DEBORAH J WILSON
Title or Position: OWNER/V.P.
Credential:
Phone: 314-535-5359