Provider Demographics
NPI:1053623645
Name:OTTO BOCK ORTHOPEDIC SERVICES LLC
Entity type:Organization
Organization Name:OTTO BOCK ORTHOPEDIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATIONAL CONTRACT MGR.
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-806-2879
Mailing Address - Street 1:PO BOX 734949
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-4949
Mailing Address - Country:US
Mailing Address - Phone:512-806-2879
Mailing Address - Fax:866-642-2302
Practice Address - Street 1:4061 BONITA BEACH RD STE 104
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-4073
Practice Address - Country:US
Practice Address - Phone:800-736-8276
Practice Address - Fax:866-642-2302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-12
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1313643332B00000X
335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ6337600001Medicare NSC
FL6337600027Medicare NSC
FL0315818 00Medicaid