MEDICARE: MR. EDMOND J RESTIVO JR. C.P.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier	331216298	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	331216298	OTHER	LA	TAX

General Provider Information

NPI Number	:	1043558976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EDMOND J RESTIVO JR. C.P.O.

Provider Business Mailing Address
First Line	:	3456 SPRING HILL AVE STE 19
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36608-1523
Country	:	US
Telephone Number	:	251-605-2529
Fax Number	:

Provider Business Practice Location Address
First Line	:	3456 SPRING HILL AVE STE 19
Second Line	:
City	:	MOBILE
State	:	AL
Zip	:	36608-1523
Country	:	US
Telephone Number	:	251-605-2529
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2013
Last Update Date	:	01/28/2013

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Directions to “ MR. EDMOND J RESTIVO JR. C.P.O.” Practice Location

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