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General NPI Number Information
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NPI Number | 1912303330
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Entity Type | Organization
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Legal Business Name | PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-SOUTHEAST, LLC
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Dates
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Enumeration Date | 11/12/2014
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Last Update Date | 04/23/2025
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Provider Practice Location Address
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Address Line | 3100 SAMFORD AVE
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City | SHREVEPORT
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State | LA
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Zip | 71103-4239
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Country | US
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Telephone | 318-226-3310
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Fax | 318-226-4294
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Provider Business Mailing Address
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Address Line | PO BOX 947109
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City | ATLANTA
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State | GA
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Zip | 30394-7109
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Country | US
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Telephone | 318-226-3310
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Fax | 813-226-4294
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Authorized Official
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Title or Position | DIRECTOR OF O&P
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Name | MR. JOSEPH ANTHONY GOMEZ
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Credential | BOCO
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Telephone | 318-226-4279
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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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