Healthcare Provider Details

I. General information

NPI: 1538163183
Provider Name (Legal Business Name): PEDIATRIC PROSTHETICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12926 WILLOW CHASE DR
HOUSTON TX
77070-5641
US

IV. Provider business mailing address

12926 WILLOW CHASE DR
HOUSTON TX
77070-5641
US

V. Phone/Fax

Practice location:
  • Phone: 281-897-1108
  • Fax: 281-897-8462
Mailing address:
  • Phone: 281-897-1108
  • Fax: 281-897-8462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number101134
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number101134
License Number StateTX

VIII. Authorized Official

Name: MRS. LINDA PUTBACK-BEAN
Title or Position: PRESIDENT
Credential:
Phone: 281-897-1108