Healthcare Provider Details

I. General information

NPI: 1770535759
Provider Name (Legal Business Name): INNOVATIVE PROSTHETIC DESIGNS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 LINCOLN RD
COLUMBUS MS
39705-2225
US

IV. Provider business mailing address

PO BOX 689
AMORY MS
38821-0689
US

V. Phone/Fax

Practice location:
  • Phone: 662-240-9700
  • Fax: 662-240-9928
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOHN VINCENT UNGARO
Title or Position: PRESIDENT
Credential: CP
Phone: 662-240-9700