Provider Demographics
NPI:1144284191
Name:XTREME ORTHOTICS & PROSTHETICS, INC
Entity type:Organization
Organization Name:XTREME ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EMIL
Authorized Official - Middle Name:GEORGIO
Authorized Official - Last Name:CERULLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-357-3629
Mailing Address - Street 1:3840 W NORTHWEST HWY
Mailing Address - Street 2:SUITE 400
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75220-5162
Mailing Address - Country:US
Mailing Address - Phone:214-357-3629
Mailing Address - Fax:214-366-9555
Practice Address - Street 1:3840 W NORTHWEST HWY
Practice Address - Street 2:SUITE 400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75220-5162
Practice Address - Country:US
Practice Address - Phone:214-357-3629
Practice Address - Fax:214-366-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0088519332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0088519OtherSTATE LICENSE
TX4603630001Medicare ID - Type Unspecified