MEDICARE: RELIANT PROSTHETICS SOUTHWEST, LLC

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	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1235424177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RELIANT PROSTHETICS SOUTHWEST, LLC

Provider Business Mailing Address
First Line	:	1300 COUNTRY CLUB RD
Second Line	:	SUITE B
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9449
Country	:	US
Telephone Number	:	575-589-3200
Fax Number	:	575-589-3201

Provider Business Practice Location Address
First Line	:	1300 COUNTRY CLUB RD
Second Line	:	SUITE B
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-9449
Country	:	US
Telephone Number	:	575-589-3200
Fax Number	:	575-589-3201

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. TOM L LOPOSER JR.
Credential	:
Telephone Number	:	972-470-0300

Provider Enumeration Date	:	06/17/2011
Last Update Date	:	09/08/2011

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