Provider Demographics
NPI:1316071756
Name:BERRY ORTHOTICS & PROSTHETICS, INC.
Entity type:Organization
Organization Name:BERRY ORTHOTICS & PROSTHETICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LPO
Authorized Official - Phone:352-253-9255
Mailing Address - Street 1:405 E ALFRED ST
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-3301
Mailing Address - Country:US
Mailing Address - Phone:352-253-9255
Mailing Address - Fax:352-253-9045
Practice Address - Street 1:405 E ALFRED ST
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-3301
Practice Address - Country:US
Practice Address - Phone:352-253-9255
Practice Address - Fax:352-253-9045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORT3, PRO37335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4671980001Medicare ID - Type Unspecified