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General NPI Number Information
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NPI Number | 1275998908
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Entity Type | Organization
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Legal Business Name | SOUTHEAST ORTHOPEDIC SPECIALISTS, INC
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Dates
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Enumeration Date | 12/23/2015
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Last Update Date | 09/29/2022
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Provider Practice Location Address
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Address Line | 10475 CENTURION PKWY N SUITE 220
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City | JACKSONVILLE
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State | FL
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Zip | 32256-5003
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Country | US
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Telephone | 904-634-0640
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Fax | 904-634-0203
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Provider Business Mailing Address
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Address Line | 10475 CENTURION PKWY N STE 220
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City | JACKSONVILLE
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State | FL
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Zip | 32256-5004
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Country | US
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Telephone | 904-634-0640
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Fax | 904-634-0203
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Authorized Official
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Title or Position | PRESIDENT
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Name | BRETT PUCKETT
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Credential |
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Telephone | 904-634-0640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | ME80485
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License Number State | FL
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