Healthcare Provider Details

I. General information

NPI: 1083839062
Provider Name (Legal Business Name): INTERCOASTAL ORTHOTICS & PROSTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 08/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PELICAN DR STE A
EDGEWATER FL
32141-4254
US

IV. Provider business mailing address

1 PELICAN DR STE A
EDGEWATER FL
32141-4254
US

V. Phone/Fax

Practice location:
  • Phone: 386-409-9432
  • Fax: 386-409-9433
Mailing address:
  • Phone: 386-409-9432
  • Fax: 386-409-9433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPOR 162
License Number StateFL

VIII. Authorized Official

Name: MR. TOM HARVEY MOWERY
Title or Position: PROSTHETIST, ORTHOTIST
Credential: CPO,LPO
Phone: 386-409-9432