Healthcare Provider Details

I. General information

NPI: 1962014100
Provider Name (Legal Business Name): ORTHOTIC & PROSTHETIC SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2020
Last Update Date: 09/06/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 N FLOWOOD DR STE B4
JACKSON MS
39232-9738
US

IV. Provider business mailing address

7754 FLORIDA BLVD
BATON ROUGE LA
70806-4706
US

V. Phone/Fax

Practice location:
  • Phone: 769-777-7440
  • Fax: 985-256-2599
Mailing address:
  • Phone: 225-243-9736
  • Fax: 985-256-2599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: DANDRE SHONDALE MOSTELLA
Title or Position: OWNER
Credential: CP
Phone: 225-316-5444