Healthcare Provider Details

I. General information

NPI: 1750323713
Provider Name (Legal Business Name): EDGAR DE LA FUENTE LICENSED PROSTHETIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DBA VRAI PROSTHETIC CARE

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 N. SECOND STREET
LONGVIEW TX
75601-5316
US

IV. Provider business mailing address

719 N. SECOND STREET
LONGVIEW TX
75601-5316
US

V. Phone/Fax

Practice location:
  • Phone: 903-553-1040
  • Fax: 903-553-9996
Mailing address:
  • Phone: 903-553-1040
  • Fax: 903-553-9996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number233
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: