Provider Demographics
NPI:1770763179
Name:CREATIVE ORTHOTIC & PROSTHETIC SERVICES
Entity type:Organization
Organization Name:CREATIVE ORTHOTIC & PROSTHETIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:SEDILLO
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:850-398-8159
Mailing Address - Street 1:120 E REDSTONE AVE
Mailing Address - Street 2:# C
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32539-5370
Mailing Address - Country:US
Mailing Address - Phone:850-398-8159
Mailing Address - Fax:
Practice Address - Street 1:120 E REDSTONE AVE
Practice Address - Street 2:# C
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32539-5370
Practice Address - Country:US
Practice Address - Phone:850-398-8159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5941110001Medicare NSC