Healthcare Provider Details

I. General information

NPI: 1083747513
Provider Name (Legal Business Name): JSC PEDORTHICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 US HIGHWAY 1 S SUITE6
ST AUGUSTINE FL
32086-6199
US

IV. Provider business mailing address

100 S STATE ST SUITE D
BUNNELL FL
32110-6114
US

V. Phone/Fax

Practice location:
  • Phone: 904-501-2306
  • Fax:
Mailing address:
  • Phone: 386-437-0272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPED63
License Number StateFL

VIII. Authorized Official

Name: SCOTT D REEDY
Title or Position: PRES.
Credential: C.PED.
Phone: 386-437-0272