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General NPI Number Information
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NPI Number | 1932405404
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Entity Type | Organization
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Legal Business Name | CREATIVE ORTHOTIC & PROSTHETIC SERVICES
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Dates
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Enumeration Date | 02/01/2011
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Last Update Date | 02/01/2011
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Provider Practice Location Address
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Address Line | 907 MAR WALT DR STE 2011
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6756
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Country | US
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Telephone | 850-226-8546
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Fax |
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Provider Business Mailing Address
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Address Line | 907 MAR WALT DR STE 2011
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6756
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Country | US
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Telephone | 850-226-8546
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | MARY MATA
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Credential |
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Telephone | 850-226-8546
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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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