Provider Demographics
NPI:1124116025
Name:LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS, INC.
Entity type:Organization
Organization Name:LETOURNEAU LIFELIKE ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO, SECRETARY, TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LETOURNEAU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-832-5005
Mailing Address - Street 1:PO BOX 21698
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77720
Mailing Address - Country:US
Mailing Address - Phone:409-832-5005
Mailing Address - Fax:409-832-5015
Practice Address - Street 1:3516 HIGHWAY 365
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627
Practice Address - Country:US
Practice Address - Phone:409-832-5005
Practice Address - Fax:409-832-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101503335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207150802Medicaid
TX530863OtherBCBS OF TX
TX530863OtherBCBS OF TX