1386929347 NPI number — PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - SOUTHEAST, LLC

Table of content: MS. JEAN TERESA LARSON PMHNP-BC (NPI 1801257332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386929347 NPI number — PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - SOUTHEAST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - SOUTHEAST, LLC
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:
Provider Other Organization Name Type Code:
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:
1386929347
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 947109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30394-7109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-367-2876
Provider Business Mailing Address Fax Number:
813-518-7659

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15511 N FLORIDA AVE STE 602
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33613-1242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-975-7139
Provider Business Practice Location Address Fax Number:
813-631-7160
Provider Enumeration Date:
10/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
KANAS
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR O&P
Authorized Official Telephone Number:
813-975-7139

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  4184 , 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)

  • Identifier: 004604300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 117076300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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