Provider Demographics
NPI:1033130182
Name:SOUTHEAST ORTHOTICS INC
Entity Type:Organization
Organization Name:SOUTHEAST ORTHOTICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-986-9657
Mailing Address - Street 1:10506 CORY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2710
Mailing Address - Country:US
Mailing Address - Phone:813-986-9657
Mailing Address - Fax:813-982-1034
Practice Address - Street 1:17429 BRIDGE HILL CT
Practice Address - Street 2:SUITE D
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-3467
Practice Address - Country:US
Practice Address - Phone:813-615-2277
Practice Address - Fax:813-632-3377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM2602OtherBCBS OF FL
FL=========OtherTAX ID NUMBER
FL4390930001Medicare ID - Type UnspecifiedMEDICARE