=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457593790
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSITIVE IMAGE PROSTHETICS & ORTHOTICS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2009
-----------------------------------------------------
Last Update Date | 04/01/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 NEW RIVER PKWY BLDG 6 SUITE 12
-----------------------------------------------------
City | HARDEEVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29927-4450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-354-7500
-----------------------------------------------------
Fax | 912-354-7887
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5202 WATERS AVE
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31404-6230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-354-7500
-----------------------------------------------------
Fax | 912-354-7887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DAVID M PUCKETT
-----------------------------------------------------
Credential | LPO/CPO
-----------------------------------------------------
Telephone | 912-354-7500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 000028
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------