Provider Demographics
NPI:1457602443
Name:OTO-LOGIC SUPPORT SERVICES, INC
Entity Type:Organization
Organization Name:OTO-LOGIC SUPPORT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:727-204-2982
Mailing Address - Street 1:9824 54TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33708-3708
Mailing Address - Country:US
Mailing Address - Phone:727-204-2982
Mailing Address - Fax:727-319-2781
Practice Address - Street 1:360 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4449
Practice Address - Country:US
Practice Address - Phone:727-204-2982
Practice Address - Fax:727-319-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-01
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY754231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1508998766Medicare UPIN