Provider Demographics
NPI:1316363245
Name:WATERFORD ORTHOPEDICS, INC.
Entity type:Organization
Organization Name:WATERFORD ORTHOPEDICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CERECEDA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:305-450-0128
Mailing Address - Street 1:815 NW 57TH AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2054
Mailing Address - Country:US
Mailing Address - Phone:305-888-5280
Mailing Address - Fax:205-888-5299
Practice Address - Street 1:2750 CORAL WAY STE 200
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-3200
Practice Address - Country:US
Practice Address - Phone:305-461-3116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME670040174400000X
FLME31217174400000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty