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General NPI Number Information
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NPI Number | 1508447343
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Entity Type | Organization
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Legal Business Name | SOUTHLAKE ORTHOPAEDICS DBA SOUTHLAKE PROSTHETICS & ORTHOTICS
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Dates
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Enumeration Date | 04/14/2021
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Last Update Date | 02/10/2022
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Provider Practice Location Address
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Address Line | 4524 SOUTHLAKE PKWY STE 26
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City | HOOVER
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State | AL
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Zip | 35244-3272
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Country | US
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Telephone | 205-985-4111
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Fax | 205-267-4411
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Provider Business Mailing Address
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Address Line | 4517 SOUTHLAKE PKWY
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City | HOOVER
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State | AL
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Zip | 35244-3280
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Country | US
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Telephone | 205-985-4111
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Fax | 205-267-4411
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. ROBERT CRABTREE
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Credential |
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Telephone | 205-985-4111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 224P00000X
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Taxonomy Name | Prosthetist
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License Number |
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License Number State |
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