Healthcare Provider Details

I. General information

NPI: 1356397459
Provider Name (Legal Business Name): SOUTHEASTERN ORTHOTICS & PROSTHETICS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date: 05/31/2023
Reactivation Date: 06/26/2023

III. Provider practice location address

220 1ST ST NW
CLEVELAND TN
37311-1306
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: 423-266-8892
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. AARON SORENSEN
Title or Position: PRESIDENT
Credential: CPO, LPO
Phone: 615-217-9821