Provider Demographics
NPI:1972969756
Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, INC
Entity Type:Organization
Organization Name:SOUTHEAST ORTHOPEDIC SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANCILLARY MANAGER, PHYSICAL THERAPY
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-674-2023
Mailing Address - Street 1:6800 SOUTHPOINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8203
Mailing Address - Country:US
Mailing Address - Phone:904-634-0203
Mailing Address - Fax:904-634-0203
Practice Address - Street 1:2627 RIVERSIDE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4712
Practice Address - Country:US
Practice Address - Phone:904-634-0640
Practice Address - Fax:904-634-0203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80485332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4080Medicare PIN