=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346559507
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH BEACH ORTHOTICS & PROSTHETICS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2010
-----------------------------------------------------
Last Update Date | 12/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4147 SUN N LAKE BLVD
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33872-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-658-1291
-----------------------------------------------------
Fax | 305-675-3706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4147 SUN N LAKE BLVD
-----------------------------------------------------
City | SEBRING
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33872-2131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-672-9393
-----------------------------------------------------
Fax | 305-675-3706
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PRESIDENT
-----------------------------------------------------
Name | MR. MARK SELLECK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-672-9393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------