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General NPI Number Information
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NPI Number | 1164527388
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Entity Type | Organization
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Legal Business Name | BAYROAD ENTERPRISES INC DBA
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 617 BLANDING BLVD
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City | ORANGE PARK
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State | FL
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Zip | 32073-5058
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Country | US
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Telephone | 904-213-4430
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Fax | 904-276-7823
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Provider Business Mailing Address
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Address Line | PO BOX 1657
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City | ORANGE PARK
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State | FL
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Zip | 32067-1657
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Country | US
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Telephone | 904-213-4430
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Fax | 904-276-7823
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Authorized Official
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Title or Position | OWNER
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Name | MR. HENRY MOFFETT TONKIN III
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Credential | CP, LP
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Telephone | 904-213-4430
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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 |
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License Number State |
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