Provider Demographics
NPI:1912303330
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-SOUTHEAST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-SOUTHEAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF O&P
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:BOCO
Authorized Official - Phone:318-226-4279
Mailing Address - Street 1:PO BOX 865109
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-5109
Mailing Address - Country:US
Mailing Address - Phone:844-602-3960
Mailing Address - Fax:813-281-8461
Practice Address - Street 1:3100 SAMFORD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4239
Practice Address - Country:US
Practice Address - Phone:318-226-3310
Practice Address - Fax:318-226-4294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES-SOUTHEAST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-12
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier