=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255451621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M-TECH ORTHOTICS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 545 DELANEY AVE BLDG.1-B
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32801-3866
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-761-5869
-----------------------------------------------------
Fax | 407-291-7456
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7718 DEBEAUBIEN DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-8126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-318-4199
-----------------------------------------------------
Fax | 407-291-7456
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | LESLEY J. GRAVES-BOYNTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-761-5869
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | ORF175
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------