Healthcare Provider Details

I. General information

NPI: 1538292057
Provider Name (Legal Business Name): GAINESVILLE ORTHOTIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3870 NW 83RD STREET
GAINESVILLE FL
32606
US

IV. Provider business mailing address

3870 NW 83RD STREET
GAINESVILLE FL
32606
US

V. Phone/Fax

Practice location:
  • Phone: 352-331-4221
  • Fax: 352-332-8074
Mailing address:
  • Phone: 352-331-4221
  • Fax: 352-332-8074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPOR184
License Number StateFL

VIII. Authorized Official

Name: DEANNA M. CLOUGH-CHAPMAN
Title or Position: PRACTITIONER/CLINICAL MANAGER
Credential: MSPO, CPO, LPO, FAAO
Phone: 352-331-4221