Provider Demographics
NPI:1740508019
Name:PERFORMANCE PROSTHETICS & ORTHOTICS
Entity type:Organization
Organization Name:PERFORMANCE PROSTHETICS & ORTHOTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-607-6126
Mailing Address - Street 1:4304 N DAVIS HWY STE B
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2754
Mailing Address - Country:US
Mailing Address - Phone:850-607-6126
Mailing Address - Fax:850-607-6674
Practice Address - Street 1:4304 N DAVIS HWY STE B
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2754
Practice Address - Country:US
Practice Address - Phone:850-607-6126
Practice Address - Fax:850-607-6674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-12
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR 145335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002681100Medicaid