Provider Demographics
NPI:1194843797
Name:SUN STATE PROSTHETICS INC
Entity Type:Organization
Organization Name:SUN STATE PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:GANO
Authorized Official - Suffix:
Authorized Official - Credentials:LCP
Authorized Official - Phone:407-629-2866
Mailing Address - Street 1:1444 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4806
Mailing Address - Country:US
Mailing Address - Phone:407-629-2866
Mailing Address - Fax:
Practice Address - Street 1:756 BERKSHIRE RD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1602
Practice Address - Country:US
Practice Address - Phone:407-629-2866
Practice Address - Fax:407-629-4277
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUN STATE PROSTHETICS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-26
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPRO 12224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0662480002OtherPTAN