Provider Demographics
NPI:1881616720
Name:SOUTH BEACH ORTHOTICS & PROSTHETICS INC
Entity type:Organization
Organization Name:SOUTH BEACH ORTHOTICS & PROSTHETICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLECK
Authorized Official - Suffix:
Authorized Official - Credentials:ORF
Authorized Official - Phone:561-394-4200
Mailing Address - Street 1:4147 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2131
Mailing Address - Country:US
Mailing Address - Phone:305-672-9393
Mailing Address - Fax:305-675-3706
Practice Address - Street 1:4735 PALM AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4037
Practice Address - Country:US
Practice Address - Phone:305-672-9393
Practice Address - Fax:305-675-3706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-23
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC6065335E00000X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004162700Medicaid
FL5237200001Medicare NSC