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General NPI Number Information
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NPI Number | 1033130182
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Entity Type | Organization
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Legal Business Name | SOUTHEAST ORTHOTICS INC
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Dates
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Enumeration Date | 07/22/2006
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Last Update Date | 07/05/2011
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Provider Practice Location Address
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Address Line | 17429 BRIDGE HILL CT SUITE D
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City | TAMPA
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State | FL
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Zip | 33647-3467
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Country | US
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Telephone | 813-615-2277
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Fax | 813-632-3377
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Provider Business Mailing Address
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Address Line | 10506 CORY LAKE DR
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City | TAMPA
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State | FL
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Zip | 33647-2710
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Country | US
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Telephone | 813-986-9657
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Fax | 813-982-1034
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Authorized Official
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Title or Position | OWNER
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Name | BRENT E SQUIRES
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Credential |
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Telephone | 813-986-9657
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State |
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