MEDICARE: WACO 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	101602	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	101602	OTHER	TX	TEXAS DEPARTMENT OF LICENSING AND REGULATION

General Provider Information

NPI Number	:	1881182640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WACO PROSTHETICS, INC.

Provider Business Mailing Address
First Line	:	201 COLONNADE PKWY STE 101
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-6174
Country	:	US
Telephone Number	:	254-652-4898
Fax Number	:	866-981-5223

Provider Business Practice Location Address
First Line	:	201 COLONNADE PKWY STE 101
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76712-6174
Country	:	US
Telephone Number	:	254-652-4898
Fax Number	:	866-981-5223

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	MRS. LISA WILLIAMS
Credential	:
Telephone Number	:	469-400-4363

Provider Enumeration Date	:	04/27/2018
Last Update Date	:	04/27/2018

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