Provider Demographics
NPI:1326138306
Name:TIDWELL'S ORTHOTICS, LLC
Entity Type:Organization
Organization Name:TIDWELL'S ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDORTHIST/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, LPED
Authorized Official - Phone:954-346-5402
Mailing Address - Street 1:4450 NW 126TH AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-7604
Mailing Address - Country:US
Mailing Address - Phone:954-346-5402
Mailing Address - Fax:954-346-5403
Practice Address - Street 1:4450 NW 126TH AVE STE 106
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-7604
Practice Address - Country:US
Practice Address - Phone:954-346-5402
Practice Address - Fax:954-346-5403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED117332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies