1346319613 NPI number — ORTHOTIC & PROSTHETIC CLINIC INC

Table of content: (NPI 1346319613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346319613 NPI number — ORTHOTIC & PROSTHETIC CLINIC INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ORTHOTIC & PROSTHETIC CLINIC INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FENTON PROSTHETICS & ORTHOTICS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346319613
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 SE HILLMOOR DR
Provider Second Line Business Mailing Address:
C13
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34952-7552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-337-7378
Provider Business Mailing Address Fax Number:
772-337-1742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
921 E OCEAN BLVD
Provider Second Line Business Practice Location Address:
#4
Provider Business Practice Location Address City Name:
STUART
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34994
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-781-8702
Provider Business Practice Location Address Fax Number:
772-337-1742
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FENTON
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
772-337-7378

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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