Healthcare Provider Details

I. General information

NPI: 1639246234
Provider Name (Legal Business Name): FORT PIERCE ORTHOPAEDICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 09/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S 23RD ST SUITES 7 AND 8
FORT PIERCE FL
34950-4830
US

IV. Provider business mailing address

1801 S 23RD ST SUITES 7 AND 8
FORT PIERCE FL
34950-4830
US

V. Phone/Fax

Practice location:
  • Phone: 772-465-4651
  • Fax:
Mailing address:
  • Phone: 772-465-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MICKEY PICKLER
Title or Position: VP
Credential:
Phone: 850-523-2117