Provider Demographics
NPI:1538292057
Name:GAINESVILLE ORTHOTIC THERAPY
Entity Type:Organization
Organization Name:GAINESVILLE ORTHOTIC THERAPY
Other - Org Name:GAINESVILLE ORTHOTICS AND PROSTHETICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTITIONER/CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLOUGH-CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSPO, CPO, LPO, FAAO
Authorized Official - Phone:352-331-4221
Mailing Address - Street 1:3870 NW 83RD STREET
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606
Mailing Address - Country:US
Mailing Address - Phone:352-331-4221
Mailing Address - Fax:352-332-8074
Practice Address - Street 1:3870 NW 83RD STREET
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606
Practice Address - Country:US
Practice Address - Phone:352-331-4221
Practice Address - Fax:352-332-8074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR184335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL026135100Medicaid
FLM2657OtherDME PROVIDER # BCBS OF FL