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General NPI Number Information
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NPI Number | 1467953653
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Entity Type | Organization
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Legal Business Name | LONE STAR PROSTHETICS, LLC
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Dates
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Enumeration Date | 02/23/2018
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Last Update Date | 02/23/2018
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Provider Practice Location Address
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Address Line | 2201 BROOKHOLLOW PLAZA DR STE 350
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City | ARLINGTON
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State | TX
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Zip | 76006-7443
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Country | US
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Telephone | 817-649-8144
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Fax | 844-859-1443
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Provider Business Mailing Address
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Address Line | 2201 BROOKHOLLOW PLAZA DR STE 350
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City | ARLINGTON
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State | TX
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Zip | 76006-7443
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Country | US
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Telephone | 817-649-8144
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Fax | 844-859-1443
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Authorized Official
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Title or Position | OWNER/PROSTHETIC PRACTITIONER
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Name | BRYAN WESLEY PETTIT
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Credential | LICENSED PROSTHETIST
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Telephone | 817-649-8144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 101595
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License Number State | TX
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