Healthcare Provider Details

I. General information

NPI: 1194843797
Provider Name (Legal Business Name): SUN STATE PROSTHETICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 09/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

756 BERKSHIRE RD
DAYTONA BEACH FL
32114-1602
US

IV. Provider business mailing address

1444 W FAIRBANKS AVE
WINTER PARK FL
32789-4806
US

V. Phone/Fax

Practice location:
  • Phone: 407-629-2866
  • Fax: 407-629-4277
Mailing address:
  • Phone: 407-629-2866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberPRO 12
License Number StateFL

VIII. Authorized Official

Name: CHARLES F GANO
Title or Position: OWNER
Credential: LCP
Phone: 407-629-2866