Healthcare Provider Details

I. General information

NPI: 1508447343
Provider Name (Legal Business Name): SOUTHLAKE ORTHOPAEDICS DBA SOUTHLAKE PROSTHETICS & ORTHOTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4524 SOUTHLAKE PKWY STE 26
HOOVER AL
35244-3272
US

IV. Provider business mailing address

4517 SOUTHLAKE PKWY
HOOVER AL
35244-3280
US

V. Phone/Fax

Practice location:
  • Phone: 205-985-4111
  • Fax: 205-267-4411
Mailing address:
  • Phone: 205-985-4111
  • Fax: 205-267-4411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT CRABTREE
Title or Position: ADMINISTRATOR
Credential:
Phone: 205-985-4111