Provider Demographics
NPI:1942067939
Name:ORTHOTIC & PROSTHETIC CLINIC OF JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:ORTHOTIC & PROSTHETIC CLINIC OF JACKSONVILLE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / AMBR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:AGUSTIN
Authorized Official - Last Name:DIAZ ABREU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-812-5087
Mailing Address - Street 1:2754 NW 27TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-3692
Mailing Address - Country:US
Mailing Address - Phone:305-812-5087
Mailing Address - Fax:
Practice Address - Street 1:11512 LAKE MEAD AVE UNIT 404
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-9687
Practice Address - Country:US
Practice Address - Phone:904-231-8440
Practice Address - Fax:904-231-8441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-05
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier