MEDICARE: 865 PROSTHETICS, 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	224P00000X	Prosthetist
2	335E00000X	Prosthetic/Orthotic Supplier

General Provider Information

NPI Number	:	1396556114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	865 PROSTHETICS, LLC

Provider Business Mailing Address
First Line	:	5416 S MIDDLEBROOK PIKE STE A
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37921-5980
Country	:	US
Telephone Number	:	865-484-4134
Fax Number	:	865-622-5254

Provider Business Practice Location Address
First Line	:	5416 S MIDDLEBROOK PIKE STE A
Second Line	:
City	:	KNOXVILLE
State	:	TN
Zip	:	37921-5980
Country	:	US
Telephone Number	:	865-484-4134
Fax Number	:	865-622-5254

Authorized Official
Title or Position	:	DIRECTOR OF CLINICAL OPERATIONS
Name	:	MR. JASON L HAYDEN
Credential	:	CP
Telephone Number	:	865-484-4134

Provider Enumeration Date	:	01/20/2025
Last Update Date	:	07/21/2025

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