MEDICARE: SOUTHEAST ORTHOTICS INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M2602	OTHER	FL	BCBS OF FL

General Provider Information

NPI Number	:	1033130182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST ORTHOTICS INC

Provider Business Mailing Address
First Line	:	10506 CORY LAKE DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33647-2710
Country	:	US
Telephone Number	:	813-986-9657
Fax Number	:	813-982-1034

Provider Business Practice Location Address
First Line	:	17429 BRIDGE HILL CT
Second Line	:	SUITE D
City	:	TAMPA
State	:	FL
Zip	:	33647-3467
Country	:	US
Telephone Number	:	813-615-2277
Fax Number	:	813-632-3377

Authorized Official
Title or Position	:	OWNER
Name	:	BRENT E SQUIRES
Credential	:
Telephone Number	:	813-986-9657

Provider Enumeration Date	:	07/22/2006
Last Update Date	:	07/05/2011

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Directions to “SOUTHEAST ORTHOTICS INC ” Practice Location

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