Healthcare Provider Details

I. General information

NPI: 1164143905
Provider Name (Legal Business Name): SOUTHEAST ORTHOPEDIC SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1690 US HIGHWAY 1 S
ST AUGUSTINE FL
32084-4192
US

IV. Provider business mailing address

6800 SOUTHPOINT PKWY STE 200
JACKSONVILLE FL
32216-6221
US

V. Phone/Fax

Practice location:
  • Phone: 904-634-0640
  • Fax: 904-634-0203
Mailing address:
  • Phone: 904-634-0640
  • Fax: 904-634-0203

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: BRETT PUCKETT
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 904-634-0640