Provider Demographics
NPI:1205352127
Name:SOUTHERN PROSTHETIC CARE LLC
Entity type:Organization
Organization Name:SOUTHERN PROSTHETIC CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:228-216-0528
Mailing Address - Street 1:4201 HIGHWAY 11 N STE D
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2014
Mailing Address - Country:US
Mailing Address - Phone:228-216-0528
Mailing Address - Fax:769-242-2556
Practice Address - Street 1:4201 HIGHWAY 11 N STE D
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466
Practice Address - Country:US
Practice Address - Phone:228-216-0528
Practice Address - Fax:769-242-2556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Multi-Specialty
Yes335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty