MEDICARE: BAY QUALITY PROSTHETICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332BC3200X	Customized Equipment (DME)	POR31	FL

General Provider Information

NPI Number	:	1003117466
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAY QUALITY PROSTHETICS LLC

Provider Business Mailing Address
First Line	:	2195 JENKS AVE STE C
Second Line	:	STE D
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4683
Country	:	US
Telephone Number	:	850-522-5343
Fax Number	:	850-640-0901

Provider Business Practice Location Address
First Line	:	2195 JENKS AVE STE C
Second Line	:	STE D
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4683
Country	:	US
Telephone Number	:	850-522-5343
Fax Number	:	850-640-0901

Authorized Official
Title or Position	:	SOLE MBR
Name	:	MR. GLENN COTTRILL
Credential	:
Telephone Number	:	850-522-5343

Provider Enumeration Date	:	11/16/2010
Last Update Date	:	03/29/2017

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