=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144284191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | XTREME ORTHOTICS & PROSTHETICS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3840 W NORTHWEST HWY SUITE 400
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75220-5162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-357-3629
-----------------------------------------------------
Fax | 214-366-9555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3840 W NORTHWEST HWY SUITE 400
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75220-5162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-357-3629
-----------------------------------------------------
Fax | 214-366-9555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. EMIL GEORGIO CERULLO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 214-357-3629
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 0088519
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------