Provider Demographics
NPI:1548441934
Name:M D PROSTHETIC LABS,L.L.C.
Entity type:Organization
Organization Name:M D PROSTHETIC LABS,L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROSTHETIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:RIFFLE
Authorized Official - Suffix:
Authorized Official - Credentials:ABC CP BOCP
Authorized Official - Phone:318-746-5000
Mailing Address - Street 1:4859 SHED RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5493
Mailing Address - Country:US
Mailing Address - Phone:318-746-5000
Mailing Address - Fax:318-746-4000
Practice Address - Street 1:4859 SHED RD STE 200
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5493
Practice Address - Country:US
Practice Address - Phone:318-746-5000
Practice Address - Fax:318-746-4000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20011335E00000X
OK30335E00000X
LA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA6051040001Medicare NSC