Healthcare Provider Details

I. General information

NPI: 1366425746
Provider Name (Legal Business Name): PROCARE PROSTHETICS & ORTHOTICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 06/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 N FLOWOOD DR STE C1
FLOWOOD MS
39232-9738
US

IV. Provider business mailing address

1050 N FLOWOOD DR STE C1
FLOWOOD MS
39232-9738
US

V. Phone/Fax

Practice location:
  • Phone: 601-664-7004
  • Fax: 601-664-7099
Mailing address:
  • Phone: 601-664-7004
  • Fax: 601-664-7099

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: MR. STEPHEN BRET LEE
Title or Position: OWNER
Credential: CPO
Phone: 601-664-7004