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General NPI Number Information
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NPI Number | 1154798809
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Entity Type | Organization
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Legal Business Name | SOUTHERN ORTHO & SPINE BRACING, LLC
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Dates
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Enumeration Date | 08/28/2015
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Last Update Date | 08/28/2015
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Provider Practice Location Address
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Address Line | 4937 CLARK RD STE 201
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City | SARASOTA
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State | FL
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Zip | 34233-3252
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Country | US
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Telephone | 941-718-3381
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Fax |
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Provider Business Mailing Address
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Address Line | 16206 29TH CT E
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City | PARRISH
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State | FL
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Zip | 34219-1791
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Country | US
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Telephone | 941-531-4885
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JEREMY BRANT WALDRIP
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Credential |
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Telephone | 941-718-3381
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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 | FL
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