Provider Demographics
NPI:1568496479
Name:PETERMAN ORTHOTICS & PROSTHETICS LLC
Entity type:Organization
Organization Name:PETERMAN ORTHOTICS & PROSTHETICS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER CONTRACT ANALYST III
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:PO BOX 650846
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2648 34TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-3520
Practice Address - Country:US
Practice Address - Phone:806-783-8388
Practice Address - Fax:806-783-8956
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-10
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
TX588335E00000X
TX215335E00000X
TX404335E00000X
TX591335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174985503Medicaid
TX5434060002Medicare NSC