1326302928 NPI number — SOUTH BEACH ORTHOTICS & PROSTHETICS, INC

Table of content: (NPI 1326302928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326302928 NPI number — SOUTH BEACH ORTHOTICS & PROSTHETICS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH BEACH ORTHOTICS & PROSTHETICS, 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:
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:
1326302928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3350 NW 2ND AVENUE
Provider Second Line Business Mailing Address:
SUITE B-18
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-394-4200
Provider Business Mailing Address Fax Number:
561-394-4422

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4751 W 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33012-3938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
786-577-0283
Provider Business Practice Location Address Fax Number:
305-675-3706
Provider Enumeration Date:
06/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SELLECK
Authorized Official First Name:
MARK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / PRESIDENT
Authorized Official Telephone Number:
561-394-4200

Provider Taxonomy Codes

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

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





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