Healthcare Provider Details

I. General information

NPI: 1245214568
Provider Name (Legal Business Name): GASTON AVENUE PROSTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 N CENTRAL EXPY #205
DALLAS TX
75231-4395
US

IV. Provider business mailing address

9900 N CENTRAL EXPY #205
DALLAS TX
75231-4395
US

V. Phone/Fax

Practice location:
  • Phone: 214-265-5060
  • Fax: 214-265-9055
Mailing address:
  • Phone: 214-265-5060
  • Fax: 214-265-9055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0900X
TaxonomyAmputee Clinic/Center
License Number101185
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number101185
License Number StateTX

VIII. Authorized Official

Name: MS. CATHERINE AMY MILLER-MEHARY
Title or Position: PRESIDENT
Credential: CP,LP,BOCO
Phone: 214-265-5060