Provider Demographics
NPI:1639155021
Name:SOUTHERN ORTHOTICS
Entity Type:Organization
Organization Name:SOUTHERN ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:EVA
Authorized Official - Middle Name:WYNELL
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-671-1161
Mailing Address - Street 1:1601 ASHLEY CENTER
Mailing Address - Street 2:UNIT 88
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-3055
Mailing Address - Country:US
Mailing Address - Phone:229-671-1161
Mailing Address - Fax:888-886-4887
Practice Address - Street 1:1601 ASHLEY CENTER
Practice Address - Street 2:UNIT 88
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-3055
Practice Address - Country:US
Practice Address - Phone:229-671-1161
Practice Address - Fax:888-886-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
DMEPOSOtherPROVIDER NUMBER
5497270001Medicare ID - Type Unspecified