Provider Demographics
NPI:1326302928
Name:SOUTH BEACH ORTHOTICS & PROSTHETICS, INC
Entity Type:Organization
Organization Name:SOUTH BEACH ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-394-4200
Mailing Address - Street 1:3350 NW 2ND AVENUE
Mailing Address - Street 2:SUITE B-18
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431
Mailing Address - Country:US
Mailing Address - Phone:561-394-4200
Mailing Address - Fax:561-394-4422
Practice Address - Street 1:4751 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3938
Practice Address - Country:US
Practice Address - Phone:786-577-0283
Practice Address - Fax:305-675-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-28
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5237200007Medicare NSC