Provider Demographics
NPI:1386456291
Name:PREMIER ORTHOTICS & PROSTHETICS, LLC
Entity type:Organization
Organization Name:PREMIER ORTHOTICS & PROSTHETICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:321-372-5102
Mailing Address - Street 1:2202 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5958
Mailing Address - Country:US
Mailing Address - Phone:321-372-5102
Mailing Address - Fax:
Practice Address - Street 1:197 BOUGAINVILLEA DR STE B
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2402
Practice Address - Country:US
Practice Address - Phone:321-372-5102
Practice Address - Fax:321-372-5106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREMIER ORTHOTICS & PROSTHETICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier