Healthcare Provider Details

I. General information

NPI: 1982175303
Provider Name (Legal Business Name): PREMIER ORTHOTICS & PROSTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2018
Last Update Date: 01/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 BRYAN ST
MELBOURNE FL
32901-5958
US

IV. Provider business mailing address

2202 BRYAN ST
MELBOURNE FL
32901-5958
US

V. Phone/Fax

Practice location:
  • Phone: 321-372-5102
  • Fax: 321-372-5106
Mailing address:
  • Phone: 321-372-5102
  • Fax: 321-372-5106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DAWN STEWARD
Title or Position: CO-OWNER, MANAGER
Credential:
Phone: 321-704-0822