=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568596690
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHWEST FLORIDA PROSTHETIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 07/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13691 METRO PKWY SUITE 100
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-936-0033
-----------------------------------------------------
Fax | 239-936-0047
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13691 METRO PKWY SUITE 100
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-936-0033
-----------------------------------------------------
Fax | 239-936-0047
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CERTIFIED ANAPLASTOLOGIST
-----------------------------------------------------
Name | MR. GREGORY THOMAS ANERINO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 239-936-0033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------