=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164420766
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAHNKE'S ORTHOTICS & PROSTHETICS OF DEERFIELD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2005
-----------------------------------------------------
Last Update Date | 04/30/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4990 SW 72ND AVE STE 107
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-5524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-772-1299
-----------------------------------------------------
Fax | 954-772-1495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4990 SW 72ND AVE STE 107
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-5524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-772-1299
-----------------------------------------------------
Fax | 954-772-1495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | SILVIO A MARTINEZ
-----------------------------------------------------
Credential | CPO/LPO
-----------------------------------------------------
Telephone | 954-772-1299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------