MEDICARE: BOLD CITY ORTHOTICS AND PROSTHETICS, 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

General Provider Information

NPI Number	:	1992538276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOLD CITY ORTHOTICS AND PROSTHETICS, LLC

Provider Business Mailing Address
First Line	:	7563 PHILIPS HWY STE 204
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6838
Country	:	US
Telephone Number	:	904-686-8222
Fax Number	:

Provider Business Practice Location Address
First Line	:	7563 PHILIPS HWY STE 204
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6838
Country	:	US
Telephone Number	:	904-686-8222
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER, ORTHOTIST
Name	:	ANDREA DEAN
Credential	:	CO
Telephone Number	:	904-686-8222

Provider Enumeration Date	:	08/22/2024
Last Update Date	:	06/10/2026

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Directions to “BOLD CITY ORTHOTICS AND PROSTHETICS, LLC ” Practice Location

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