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General NPI Number Information
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NPI Number | 1215954045
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Entity Type | Organization
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Legal Business Name | SUN STATE PROSTHETICS INC.
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Dates
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Enumeration Date | 07/16/2006
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Last Update Date | 09/15/2016
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Provider Practice Location Address
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Address Line | 1444 W FAIRBANKS AVE
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City | WINTER PARK
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State | FL
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Zip | 32789-4806
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Country | US
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Telephone | 407-629-2866
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Fax | 407-629-4277
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Provider Business Mailing Address
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Address Line | 1444 W FAIRBANKS AVE
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City | WINTER PARK
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State | FL
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Zip | 32789-4806
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Country | US
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Telephone | 407-629-2866
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Fax | 407-629-4277
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHARLES FREDERICK GANO
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Credential | L.C.P.
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Telephone | 407-629-2866
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224P00000X
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Taxonomy Name | Prosthetist
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License Number | PRO 12
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License Number State | FL
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