Provider Demographics
NPI:1679852586
Name:INNOVATIVE PROSTHETIC CARE, LLC
Entity type:Organization
Organization Name:INNOVATIVE PROSTHETIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-470-0901
Mailing Address - Street 1:9034B CARL LEGETT RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-6234
Mailing Address - Country:US
Mailing Address - Phone:228-604-0818
Mailing Address - Fax:228-604-0815
Practice Address - Street 1:1109 WI-65 SERVICE RD N
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36618
Practice Address - Country:US
Practice Address - Phone:251-470-0901
Practice Address - Fax:251-650-1671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL535335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier