Healthcare Provider Details

I. General information

NPI: 1407848211
Provider Name (Legal Business Name): SOUTHEASTERN OSTEOPOROSIS SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4511 N DAVIS HWY SUITE 1-C
PENSACOLA FL
32503-2720
US

IV. Provider business mailing address

4511 N DAVIS HWY SUITE 1-C
PENSACOLA FL
32503-2720
US

V. Phone/Fax

Practice location:
  • Phone: 850-477-0775
  • Fax:
Mailing address:
  • Phone: 850-477-0775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471B0102X
TaxonomyBone Densitometry Radiologic Technologist
License NumberJR3419100
License Number StateFL

VIII. Authorized Official

Name: MR. STEPHEN D BAST
Title or Position: PRESIDENT
Credential: P.A.-C.
Phone: 850-477-0775