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General NPI Number Information
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NPI Number | 1649664251
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Entity Type | Organization
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Legal Business Name | SPACE COAST PROSTHETICS AND ORTHOTICS, INC.
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Dates
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Enumeration Date | 03/20/2015
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 590 SOLUTIONS WAY STE 100
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City | ROCKLEDGE
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State | FL
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Zip | 32955-3623
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Country | US
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Telephone | 321-877-4732
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Fax | 321-877-4735
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Provider Business Mailing Address
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Address Line | 590 SOLUTIONS WAY STE 100
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City | ROCKLEDGE
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State | FL
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Zip | 32955-3623
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Country | US
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Telephone | 321-877-4732
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Fax | 321-877-4735
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Authorized Official
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Title or Position | VICE PRESIDENT/CO-OWNER
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Name | MR. MICHAEL PONO MCDOWELL
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Credential | CPO
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Telephone | 321-877-4732
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 222Z00000X
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Taxonomy Name | Orthotist
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License Number | POR 134
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License Number State | FL
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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 | POR 134
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License Number State | FL
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