MEDICARE: PEDIATRIC 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	335E00000X	Prosthetic/Orthotic Supplier	101134	TX
2	225000000X	Orthotic Fitter	101134	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	531649	OTHER	TX	BLUE CROSS BLUE SHIEL
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538163183
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC PROSTHETICS, INC

Provider Business Mailing Address
First Line	:	12926 WILLOW CHASE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-5641
Country	:	US
Telephone Number	:	281-897-1108
Fax Number	:	281-897-8462

Provider Business Practice Location Address
First Line	:	12926 WILLOW CHASE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-5641
Country	:	US
Telephone Number	:	281-897-1108
Fax Number	:	281-897-8462

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. LINDA PUTBACK-BEAN
Credential	:
Telephone Number	:	281-897-1108

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	02/18/2010

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