Provider Demographics
NPI:1588087001
Name:GULF COAST ORTHOTICS & PROSTHETICS CENTER, LLC
Entity type:Organization
Organization Name:GULF COAST ORTHOTICS & PROSTHETICS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILLIANE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RODERIQUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-408-6246
Mailing Address - Street 1:21300 GERTRUDE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21300 GERTRUDE AVE
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5002
Practice Address - Country:US
Practice Address - Phone:941-408-6246
Practice Address - Fax:941-249-8956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR181332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0324051 00Medicaid
FL6028120001Medicare NSC