Provider Demographics
NPI:1386929347
Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - SOUTHEAST, LLC
Entity type:Organization
Organization Name:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - SOUTHEAST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR O&P
Authorized Official - Prefix:MS
Authorized Official - First Name:JOANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KANAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-975-7139
Mailing Address - Street 1:PO BOX 947109
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7109
Mailing Address - Country:US
Mailing Address - Phone:813-367-2876
Mailing Address - Fax:813-518-7659
Practice Address - Street 1:15511 N FLORIDA AVE STE 602
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1242
Practice Address - Country:US
Practice Address - Phone:813-975-7139
Practice Address - Fax:813-631-7160
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC ORTHOTIC AND PROSTHETIC SERVICES - SOUTHEAST, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-20
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4184335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004604300Medicaid