Provider Demographics
NPI:1306082722
Name:NEWBOLD PROSTHETICS, LLC
Entity type:Organization
Organization Name:NEWBOLD PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PRACTIONER/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:BUCKLEY
Authorized Official - Last Name:NEWBOLD
Authorized Official - Suffix:III
Authorized Official - Credentials:CP
Authorized Official - Phone:863-293-5444
Mailing Address - Street 1:1547 7TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3802
Mailing Address - Country:US
Mailing Address - Phone:863-293-5444
Mailing Address - Fax:863-293-5446
Practice Address - Street 1:1547 7TH ST SW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3802
Practice Address - Country:US
Practice Address - Phone:863-293-5444
Practice Address - Fax:863-293-5446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPRO108335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6202900001Medicare NSC