Provider Demographics
NPI:1609973395
Name:COLLINS ORTHOPEDIC LAB INC
Entity Type:Organization
Organization Name:COLLINS ORTHOPEDIC LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:407-388-0141
Mailing Address - Street 1:320 PINEY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CASSELBERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32707-3806
Mailing Address - Country:US
Mailing Address - Phone:407-388-0141
Mailing Address - Fax:407-388-1121
Practice Address - Street 1:320 PINEY RIDGE RD
Practice Address - Street 2:
Practice Address - City:CASSELBERRY
Practice Address - State:FL
Practice Address - Zip Code:32707-3806
Practice Address - Country:US
Practice Address - Phone:407-388-0141
Practice Address - Fax:407-388-1121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR 120335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPOR 120OtherLICENSE P & O
FL5644210001Medicare NSC