Provider Demographics
NPI:1861685083
Name:TAMPA BAY ORTHOPAEDIC DESIGNS, INC.
Entity Type:Organization
Organization Name:TAMPA BAY ORTHOPAEDIC DESIGNS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLAF
Authorized Official - Middle Name:MICKLE
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:PROSTHETIST/ORTHOTIS
Authorized Official - Phone:813-661-9162
Mailing Address - Street 1:667 S KINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6048
Mailing Address - Country:US
Mailing Address - Phone:813-661-9162
Mailing Address - Fax:813-662-9347
Practice Address - Street 1:667 S KINGS AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4885
Practice Address - Country:US
Practice Address - Phone:813-661-9162
Practice Address - Fax:813-662-9347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAMPA BAY ORTHOPAEDIC DESIGNS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-21
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR124335E00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM2713OtherBC/BS OF FL
FL1861685083OtherNPI