| Name | Value |
|---|---|
| PROVIDER TYPE | Other Service Providers |
| CLASSIFICATION | Specialist |
| AREA OF SPECIALIZATION | Prosthetics Case Management |
| STATUS | Active |
| VA CODE | V081905 |
| X12 CODE | 1744P3200X |
| INDIVIDUAL/NON | INDIVIDUAL |
| MASTER ENTRY FOR VUID | YES |
| VUID | 5253209 |
| EFFECTIVE DATE/TIME |
|