Provider Demographics
NPI:1386788636
Name:FOURROUX PROSTHETICS, INC
Entity type:Organization
Organization Name:FOURROUX PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:W
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:256-534-8672
Mailing Address - Street 1:2743 BOB WALLACE AVE SW
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805
Mailing Address - Country:US
Mailing Address - Phone:256-534-8672
Mailing Address - Fax:800-963-5010
Practice Address - Street 1:6740 REESE ROAD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38133-4978
Practice Address - Country:US
Practice Address - Phone:901-383-1837
Practice Address - Fax:800-963-5010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4336479OtherBCBS OF TENNESSEE
TN1530932Medicaid