Healthcare Provider Details

I. General information

NPI: 1447223557
Provider Name (Legal Business Name): SOUTHEASTERN ORTHOTICS & PROSTHETICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 1ST ST NW
CLEVELAND TN
37311-5006
US

IV. Provider business mailing address

PO BOX 305172
NASHVILLE TN
37230-5172
US

V. Phone/Fax

Practice location:
  • Phone: 423-559-0500
  • Fax: 423-559-0541
Mailing address:
  • Phone: 423-559-0500
  • Fax: 423-559-0541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State

VIII. Authorized Official

Name: LAUREN VAUGHN
Title or Position: VP OF OPERATIONS
Credential:
Phone: 615-890-2160