Healthcare Provider Details

I. General information

NPI: 1316071756
Provider Name (Legal Business Name): BERRY ORTHOTICS & PROSTHETICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 10/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 E ALFRED ST
TAVARES FL
32778-3301
US

IV. Provider business mailing address

405 E ALFRED ST
TAVARES FL
32778-3301
US

V. Phone/Fax

Practice location:
  • Phone: 352-253-9255
  • Fax: 352-253-9045
Mailing address:
  • Phone: 352-253-9255
  • Fax: 352-253-9045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberORT3, PRO37
License Number StateFL

VIII. Authorized Official

Name: DANIEL ROBERT BERRY
Title or Position: PRESIDENT
Credential: LPO
Phone: 352-253-9255