Healthcare Provider Details

I. General information

NPI: 1386929347
Provider Name (Legal Business Name): PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - SOUTHEAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2011
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15511 N FLORIDA AVE STE 102
TAMPA FL
33613-1263
US

IV. Provider business mailing address

PO BOX 947109
ATLANTA GA
30394-7109
US

V. Phone/Fax

Practice location:
  • Phone: 813-975-7139
  • Fax: 813-631-7160
Mailing address:
  • Phone: 813-367-2876
  • Fax: 813-518-7659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number4184
License Number StateFL

VIII. Authorized Official

Name: MS. JOANNE KANAS
Title or Position: EXECUTIVE DIRECTOR O&P
Credential:
Phone: 813-975-7139