Provider Demographics
NPI:1356538821
Name:TREASURE COAST PEDORTHICS INC
Entity type:Organization
Organization Name:TREASURE COAST PEDORTHICS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALTHEA
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPED, LPED
Authorized Official - Phone:772-562-9045
Mailing Address - Street 1:2686 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-5080
Mailing Address - Country:US
Mailing Address - Phone:772-562-9045
Mailing Address - Fax:772-562-9436
Practice Address - Street 1:2686 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-5080
Practice Address - Country:US
Practice Address - Phone:772-562-9045
Practice Address - Fax:772-562-9436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPED 78335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6069660001Medicare NSC