MEDICARE: ORTHOTIC & PROSTHETIC CLINIC OF TAMPA, LLC

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
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1497530810
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOTIC & PROSTHETIC CLINIC OF TAMPA, LLC

Provider Business Mailing Address
First Line	:	2754 NW 27TH AVE
Second Line	:
City	:	BOCA RATON
State	:	FL
Zip	:	33434-3692
Country	:	US
Telephone Number	:	305-812-5087
Fax Number	:

Provider Business Practice Location Address
First Line	:	34760 US HIGHWAY 19 N
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34684-2120
Country	:	US
Telephone Number	:	813-466-5006
Fax Number	:	813-531-8385

Authorized Official
Title or Position	:	OWNER / AMBR
Name	:	MR. RAFAEL AGUSTIN DIAZ ABREU
Credential	:
Telephone Number	:	305-812-5087

Provider Enumeration Date	:	08/25/2023
Last Update Date	:	06/14/2024

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