Provider Demographics
NPI:1063050862
Name:SOUTHERN PROSTHETIC CARE LLC
Entity type:Organization
Organization Name:SOUTHERN PROSTHETIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:228-265-7847
Mailing Address - Street 1:1308 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2552
Mailing Address - Country:US
Mailing Address - Phone:228-265-7847
Mailing Address - Fax:228-265-7876
Practice Address - Street 1:1308 44TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2552
Practice Address - Country:US
Practice Address - Phone:228-265-7847
Practice Address - Fax:228-265-7876
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN PROSTHETIC CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-12
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier