=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508048984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST TEXAS PROSTHETIC-ORTHOTIC CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2007
-----------------------------------------------------
Last Update Date | 06/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 812 N 4TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-5413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-236-4488
-----------------------------------------------------
Fax | 903-236-4607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 812 N 4TH ST
-----------------------------------------------------
City | LONGVIEW
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75601-5413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-236-4488
-----------------------------------------------------
Fax | 903-236-4607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | MR. ROBERT M. WRIGHT III
-----------------------------------------------------
Credential | C.P.O.
-----------------------------------------------------
Telephone | 903-236-4488
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 000020
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------