Provider Demographics
NPI:1538163183
Name:PEDIATRIC PROSTHETICS, INC
Entity type:Organization
Organization Name:PEDIATRIC PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUTBACK-BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-897-1108
Mailing Address - Street 1:12926 WILLOW CHASE DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-5641
Mailing Address - Country:US
Mailing Address - Phone:281-897-1108
Mailing Address - Fax:281-897-8462
Practice Address - Street 1:12926 WILLOW CHASE DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-5641
Practice Address - Country:US
Practice Address - Phone:281-897-1108
Practice Address - Fax:281-897-8462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101134335E00000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX531649OtherBLUE CROSS BLUE SHIEL
TX1670572-01Medicaid
TX1670572-01Medicaid