Provider Demographics
NPI:1215268248
Name:RIVER CITY ORTHOTICS AND PROSTHETICS, LLC
Entity type:Organization
Organization Name:RIVER CITY ORTHOTICS AND PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BERARDELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-485-1844
Mailing Address - Street 1:16607 BLANCO ROAD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-1940
Mailing Address - Country:US
Mailing Address - Phone:210-485-1844
Mailing Address - Fax:
Practice Address - Street 1:16607 BLANCO RD
Practice Address - Street 2:SUITE 303
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-1940
Practice Address - Country:US
Practice Address - Phone:210-485-1844
Practice Address - Fax:210-439-9504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209-10982335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1659601946Other209-10982
TX1659601946OtherC21287