Healthcare Provider Details

I. General information

NPI: 1942067939
Provider Name (Legal Business Name): ORTHOTIC & PROSTHETIC CLINIC OF JACKSONVILLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11512 LAKE MEAD AVE UNIT 404
JACKSONVILLE FL
32256-9687
US

IV. Provider business mailing address

2754 NW 27TH AVE
BOCA RATON FL
33434-3692
US

V. Phone/Fax

Practice location:
  • Phone: 904-231-8440
  • Fax: 904-231-8441
Mailing address:
  • Phone: 305-812-5087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. RAFAEL AGUSTIN DIAZ ABREU
Title or Position: OWNER / AMBR
Credential:
Phone: 305-812-5087