Provider Demographics
NPI:1902366180
Name:SOUNDSIDE ORTHOTICS & PROSTHETICS, LLC
Entity Type:Organization
Organization Name:SOUNDSIDE ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:COASTAL PROSTHETICS & ORTHOTICS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-736-7976
Mailing Address - Street 1:4110 DR M.L.K. JR BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-6042
Mailing Address - Country:US
Mailing Address - Phone:252-638-1312
Mailing Address - Fax:
Practice Address - Street 1:4110 DR MARTIN LUTHER KING JR BLVD STE C
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-2270
Practice Address - Country:US
Practice Address - Phone:252-638-1312
Practice Address - Fax:252-400-1266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1316098023OtherNPI