Basic Information
| Provider Information | |||||||||
| NPI: | 1316138241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | J & C ORTHOTICS AND PROSTHETICS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | J & C ORTHOTICS & PROSTHETICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3195 CALDER ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098338600 | ||||||||
| FaxNumber: | 4098338605 | ||||||||
| Practice Location | |||||||||
| Address1: | 3195 CALDER ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777021410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098338600 | ||||||||
| FaxNumber: | 4098338605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2007 | ||||||||
| LastUpdateDate: | 09/05/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHANCE | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
| AuthorizedOfficialMiddleName: | GAYE | ||||||||
| AuthorizedOfficialTitleorPosition: | ORTHOTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4098338600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LOCO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 101129 | TX | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 332B00000X | 101129 | TX | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 21919 | 01 | UTMB CHIPS | OTHER | 4867530001 | 01 | TX | MEDICARE DMEPOS | OTHER | 2460841 | 01 | UNITED HEALTHCARE | OTHER | 10018181 | 01 | AMERIGROUP | OTHER | 164392601 | 05 | TX | MEDICAID | 531812 | 01 | TX | BLU CROSS BLUE SHIELD | OTHER |