Provider Demographics
NPI:1568596690
Name:SOUTHWEST FLORIDA PROSTHETIC CLINIC
Entity Type:Organization
Organization Name:SOUTHWEST FLORIDA PROSTHETIC CLINIC
Other - Org Name:SOUTHWEST FLORIDA PROSTHETIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CERTIFIED ANAPLASTOLOGIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:ANERINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-936-0033
Mailing Address - Street 1:13691 METRO PKWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4327
Mailing Address - Country:US
Mailing Address - Phone:239-936-0033
Mailing Address - Fax:239-936-0047
Practice Address - Street 1:13691 METRO PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4327
Practice Address - Country:US
Practice Address - Phone:239-936-0033
Practice Address - Fax:239-936-0047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0643280001Medicare NSC