Provider Demographics
NPI:1932483831
Name:PERFORMANCE PROSTHETICS & ORTHOTICS, PL
Entity Type:Organization
Organization Name:PERFORMANCE PROSTHETICS & ORTHOTICS, PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-607-6126
Mailing Address - Street 1:3010 N 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-4067
Mailing Address - Country:US
Mailing Address - Phone:850-607-6126
Mailing Address - Fax:850-607-6674
Practice Address - Street 1:15467 ALABAMA 59
Practice Address - Street 2:UNIT 1
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36567-4043
Practice Address - Country:US
Practice Address - Phone:850-607-6126
Practice Address - Fax:850-607-6674
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PERFORMANCE PROSTHETICS & ORTHOTICS, PL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-11
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR145335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002681100Medicaid
6415190001Medicare NSC