Provider Demographics
NPI:1275906653
Name:PENINSULA ORTHOTICS
Entity Type:Organization
Organization Name:PENINSULA ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:L
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-502-4466
Mailing Address - Street 1:6131 LAKE WORTH RD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3048
Mailing Address - Country:US
Mailing Address - Phone:561-502-4466
Mailing Address - Fax:
Practice Address - Street 1:6131 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3048
Practice Address - Country:US
Practice Address - Phone:561-502-4466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED56332B00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier