Healthcare Provider Details

I. General information

NPI: 1972812014
Provider Name (Legal Business Name): PENSACOLA ORTHOTIC & PROSTHETIC SPECIALTIES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2010
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5855 CREEK STATION DR
PENSACOLA FL
32504-8626
US

IV. Provider business mailing address

5855 CREEK STATION DR
PENSACOLA FL
32504-8626
US

V. Phone/Fax

Practice location:
  • Phone: 850-478-7676
  • Fax: 850-478-7699
Mailing address:
  • Phone: 850-478-7676
  • Fax: 850-478-7699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberORT17
License Number StateFL

VIII. Authorized Official

Name: THOMAS D DECKERT
Title or Position: PRESIDENT
Credential: C.O.
Phone: 850-478-7676