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General NPI Number Information
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NPI Number | 1083747513
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Entity Type | Organization
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Legal Business Name | JSC PEDORTHICS
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Dates
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Enumeration Date | 03/13/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2600 US HIGHWAY 1 S SUITE6
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City | ST AUGUSTINE
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State | FL
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Zip | 32086-6199
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Country | US
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Telephone | 904-501-2306
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Fax |
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Provider Business Mailing Address
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Address Line | 100 S STATE ST SUITE D
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City | BUNNELL
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State | FL
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Zip | 32110-6114
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Country | US
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Telephone | 386-437-0272
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Fax |
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Authorized Official
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Title or Position | PRES.
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Name | SCOTT D REEDY
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Credential | C.PED.
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Telephone | 386-437-0272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | PED63
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License Number State | FL
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