Provider Demographics
NPI:1477855922
Name:STEELE, JACK R (CERTIFIED ORTHOTIST)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:R
Last Name:STEELE
Suffix:
Gender:M
Credentials:CERTIFIED ORTHOTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6655 QUINCE RD
Mailing Address - Street 2:SUITE 124
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-8037
Mailing Address - Country:US
Mailing Address - Phone:901-757-5461
Mailing Address - Fax:
Practice Address - Street 1:6655 QUINCE RD
Practice Address - Street 2:SUITE 124
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8037
Practice Address - Country:US
Practice Address - Phone:901-757-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-02
Last Update Date:2011-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN110005528335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier