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General NPI Number Information
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NPI Number | 1114479706
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Entity Type | Organization
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Legal Business Name | PROSTHETIC TECHNOLOGY CENTER
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Dates
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Enumeration Date | 10/28/2016
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Last Update Date | 10/28/2016
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Provider Practice Location Address
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Address Line | 1700 N DIXIE HWY STE 107
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City | BOCA RATON
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State | FL
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Zip | 33432-1807
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Country | US
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Telephone | 562-373-8667
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Fax | 855-611-8511
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Provider Business Mailing Address
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Address Line | 1700 N DIXIE HWY STE 107
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City | BOCA RATON
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State | FL
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Zip | 33432-1807
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Country | US
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Telephone | 562-373-8667
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Fax | 855-611-8511
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Authorized Official
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Title or Position | LICENSED PROSTHETIST
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Name | JOHN LIBER MOSQUERA CASTRO
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Credential | CP/LP
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Telephone | 562-373-8667
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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 | PRO 174
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License Number State | FL
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