Provider Demographics
NPI:1366425746
Name:PROCARE PROSTHETICS & ORTHOTICS, INC.
Entity type:Organization
Organization Name:PROCARE PROSTHETICS & ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:BRET
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:601-664-7004
Mailing Address - Street 1:1050 N FLOWOOD DR
Mailing Address - Street 2:STE C1
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9738
Mailing Address - Country:US
Mailing Address - Phone:601-664-7004
Mailing Address - Fax:601-664-7099
Practice Address - Street 1:1050 N FLOWOOD DR
Practice Address - Street 2:STE C1
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9738
Practice Address - Country:US
Practice Address - Phone:601-664-7004
Practice Address - Fax:601-664-7099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00440983Medicaid
4474790001Medicare NSC