Provider Demographics
NPI:1649237389
Name:SOUTHERN ORTHOTICS, INC.
Entity type:Organization
Organization Name:SOUTHERN ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:W
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-216-0102
Mailing Address - Street 1:462 MEMORY LN
Mailing Address - Street 2:SUITE 120
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-4314
Mailing Address - Country:US
Mailing Address - Phone:706-216-0102
Mailing Address - Fax:706-216-0102
Practice Address - Street 1:462 MEMORY LN
Practice Address - Street 2:SUITE 120
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-4314
Practice Address - Country:US
Practice Address - Phone:706-216-0102
Practice Address - Fax:706-216-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00972881AMedicaid
GA82-00286OtherEVERCARE
GA4342520001Medicare NSC