Provider Demographics
NPI:1629043047
Name:PRECISION ORTHOTICS & PROSTHETICS, LLC
Entity type:Organization
Organization Name:PRECISION ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-864-8783
Mailing Address - Street 1:102 WOODMONT BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37205-5249
Mailing Address - Country:US
Mailing Address - Phone:615-864-8790
Mailing Address - Fax:615-454-5352
Practice Address - Street 1:8915 S PECOS RD
Practice Address - Street 2:SUITE 18A
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7149
Practice Address - Country:US
Practice Address - Phone:702-243-7671
Practice Address - Fax:702-259-7671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-20
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100509314OtherMEDICAID