Healthcare Provider Details

I. General information

NPI: 1346319613
Provider Name (Legal Business Name): ORTHOTIC & PROSTHETIC CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/21/2022
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 E OCEAN BLVD #4
STUART FL
34994
US

IV. Provider business mailing address

1701 SE HILLMOOR DR C13
PORT ST LUCIE FL
34952-7552
US

V. Phone/Fax

Practice location:
  • Phone: 772-781-8702
  • Fax: 772-337-1742
Mailing address:
  • Phone: 772-337-7378
  • Fax: 772-337-1742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. JAMES R FENTON
Title or Position: OWNER PRESIDENT
Credential: CPO LPO
Phone: 772-337-7378