Provider Demographics
NPI:1649664251
Name:SPACE COAST PROSTHETICS AND ORTHOTICS, INC.
Entity type:Organization
Organization Name:SPACE COAST PROSTHETICS AND ORTHOTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PONO
Authorized Official - Last Name:MCDOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:321-877-4732
Mailing Address - Street 1:590 SOLUTIONS WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3623
Mailing Address - Country:US
Mailing Address - Phone:321-877-4732
Mailing Address - Fax:321-877-4735
Practice Address - Street 1:590 SOLUTIONS WAY STE 100
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3623
Practice Address - Country:US
Practice Address - Phone:321-877-4732
Practice Address - Fax:321-877-4735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-20
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR 134222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15382200Medicaid