Provider Demographics
NPI:1346245081
Name:BAY PROSTHETIC CENTER
Entity type:Organization
Organization Name:BAY PROSTHETIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:E
Authorized Official - Last Name:COTTRILL
Authorized Official - Suffix:II
Authorized Official - Credentials:CPO
Authorized Official - Phone:850-863-5959
Mailing Address - Street 1:930 MAR WALT DR
Mailing Address - Street 2:STE D
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6706
Mailing Address - Country:US
Mailing Address - Phone:850-863-5959
Mailing Address - Fax:850-863-5977
Practice Address - Street 1:930 MAR WALT DR
Practice Address - Street 2:STE D
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6706
Practice Address - Country:US
Practice Address - Phone:850-863-5959
Practice Address - Fax:850-863-5977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR31335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM2541OtherBCBS PROVIDER NUMBER
FLM2541OtherBCBS PROVIDER NUMBER
FLM2541OtherBCBS PROVIDER NUMBER