Provider Demographics
NPI:1346319613
Name:ORTHOTIC & PROSTHETIC CLINIC INC
Entity Type:Organization
Organization Name:ORTHOTIC & PROSTHETIC CLINIC INC
Other - Org Name:FENTON PROSTHETICS & ORTHOTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:FENTON
Authorized Official - Suffix:
Authorized Official - Credentials:CPO LPO
Authorized Official - Phone:772-337-7378
Mailing Address - Street 1:1701 SE HILLMOOR DR
Mailing Address - Street 2:C13
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7552
Mailing Address - Country:US
Mailing Address - Phone:772-337-7378
Mailing Address - Fax:772-337-1742
Practice Address - Street 1:921 E OCEAN BLVD
Practice Address - Street 2:#4
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-781-8702
Practice Address - Fax:772-337-1742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1226360002Medicare ID - Type Unspecified