Provider Demographics
NPI:1992934053
Name:PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC.
Entity type:Organization
Organization Name:PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:P
Authorized Official - Last Name:MCCLELLAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:903-592-6574
Mailing Address - Street 1:414 E LOOP 281
Mailing Address - Street 2:SUITE 20
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7930
Mailing Address - Country:US
Mailing Address - Phone:903-234-2027
Mailing Address - Fax:903-595-3862
Practice Address - Street 1:414 E LOOP 281
Practice Address - Street 2:SUITE 20
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7930
Practice Address - Country:US
Practice Address - Phone:903-234-2027
Practice Address - Fax:903-595-3862
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROSTHETIC-ORTHOTIC ASSOCIATES OF EAST TEXAS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101070335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier