Basic Information
| Provider Information | |||||||||
| NPI: | 1972969756 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST ORTHOPEDIC SPECIALISTS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6800 SOUTHPOINT PKWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322168203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340203 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Practice Location | |||||||||
| Address1: | 2627 RIVERSIDE AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322044712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046340640 | ||||||||
| FaxNumber: | 9046340203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2016 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | MORA | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDRA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ANCILLARY MANAGER, PHYSICAL THERAPY | ||||||||
| AuthorizedOfficialTelephone: | 9046742023 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | ME80485 | FL | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.