MEDICARE: XTREME ORTHOTICS & PROSTHETICS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	0088519	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0088519	OTHER	TX	STATE LICENSE

General Provider Information

NPI Number	:	1144284191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	XTREME ORTHOTICS & PROSTHETICS, INC

Provider Business Mailing Address
First Line	:	3840 W NORTHWEST HWY
Second Line	:	SUITE 400
City	:	DALLAS
State	:	TX
Zip	:	75220-5162
Country	:	US
Telephone Number	:	214-357-3629
Fax Number	:	214-366-9555

Provider Business Practice Location Address
First Line	:	3840 W NORTHWEST HWY
Second Line	:	SUITE 400
City	:	DALLAS
State	:	TX
Zip	:	75220-5162
Country	:	US
Telephone Number	:	214-357-3629
Fax Number	:	214-366-9555

Authorized Official
Title or Position	:	CEO
Name	:	MR. EMIL GEORGIO CERULLO
Credential	:
Telephone Number	:	214-357-3629

Provider Enumeration Date	:	04/14/2006
Last Update Date	:	08/22/2020

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