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General NPI Number Information
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NPI Number | 1629061007
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Entity Type | Organization
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Legal Business Name | TAMPA BAY ORTHOPAEDIC DESIGNS INC
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Dates
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Enumeration Date | 08/31/2005
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Last Update Date | 12/18/2019
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Provider Practice Location Address
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Address Line | 812 W MARTIN LUTHER KING BLVD STE 100
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City | TAMPA
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State | FL
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Zip | 33603-3338
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Country | US
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Telephone | 813-224-0525
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Fax | 813-224-0622
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Provider Business Mailing Address
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Address Line | 812 W MARTIN LUTHER KING BLVD STE 100
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City | TAMPA
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State | FL
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Zip | 33603-3338
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Country | US
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Telephone | 813-224-0525
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Fax | 813-224-0622
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | MR. OLAF MICKLE HOLM SR.
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Credential | LPO, CO, BOCPO
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Telephone | 813-224-0525
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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 | POR124
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License Number State | FL
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