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NPI Code Detail

MEDICARE: PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC.

MEDICARE: PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, 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
1335E00000XProsthetic/Orthotic Supplier000086TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1079440601OTHERTXCSHCN-ORTHOTICS
2079439801OTHERTXCSHCN-PROTHETICS
3515809OTHERBCBS-TEXAS
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1780624148
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC.
Provider Business Mailing Address
First Line : 1028 E IDEL ST
Second Line :
City : TYLER
State : TX
Zip : 75701-2024
Country : US
Telephone Number : 903-592-6574
Fax Number : 903-595-3862
Provider Business Practice Location Address
First Line : 1028 E IDEL ST
Second Line :
City : TYLER
State : TX
Zip : 75701-2024
Country : US
Telephone Number : 903-592-6574
Fax Number : 903-595-3862
Authorized Official
Title or Position : PRESIDENT/OWNER
Name : BRUCE P. MCCLELLAN
Credential : CPO
Telephone Number : 903-592-6574
Provider Enumeration Date : 06/07/2006
Last Update Date : 07/16/2021

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Directions to “PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC. ” Practice Location

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