=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255841482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROSTHETIC ONE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2017
-----------------------------------------------------
Last Update Date | 01/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3050 S CENTER ST STE 120
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76014-2154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-323-5921
-----------------------------------------------------
Fax | 682-323-5974
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3050 S CENTER ST STE 120
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76014-2154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-323-5921
-----------------------------------------------------
Fax | 682-323-5974
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MARCUS T BAKER
-----------------------------------------------------
Credential | CPO/L
-----------------------------------------------------
Telephone | 901-795-1776
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 101575
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------