Healthcare Provider Details

I. General information

NPI: 1922615830
Provider Name (Legal Business Name): SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SHIRCLIFF WAY STE 605
JACKSONVILLE FL
32204-4762
US

IV. Provider business mailing address

6800 SOUTHPOINT PKWY STE 300
JACKSONVILLE FL
32216-8203
US

V. Phone/Fax

Practice location:
  • Phone: 904-634-0640
  • Fax: 904-634-0203
Mailing address:
  • Phone: 904-634-0640
  • Fax: 904-634-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: BRETT CHRISTOPHER PUCKETT
Title or Position: PRESIDENT
Credential: MD
Phone: 904-634-0640