Healthcare Provider Details

I. General information

NPI: 1366680134
Provider Name (Legal Business Name): ROBERT CHARLES SUTTON C.O.,L.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2009
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 NE 1ST ST
CHIEFLAND FL
32626-0920
US

IV. Provider business mailing address

113 NE 1ST ST
CHIEFLAND FL
32626-0920
US

V. Phone/Fax

Practice location:
  • Phone: 352-493-0360
  • Fax: 352-493-0369
Mailing address:
  • Phone: 352-493-0360
  • Fax: 352-493-0369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberORT 92
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: