Healthcare Provider Details

I. General information

NPI: 1730815184
Provider Name (Legal Business Name): SOUTHEAST ORTHOPEDIC SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 05/24/2025
Certification Date: 05/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GROOVER LOOP STE 201
ST AUGUSTINE FL
32086-6586
US

IV. Provider business mailing address

6800 SOUTHPOINT PKWY STE 300
JACKSONVILLE FL
32216-8203
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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