Provider Demographics
NPI:1730587585
Name:ORTHOCLINIC, INC.
Entity type:Organization
Organization Name:ORTHOCLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-630-5402
Mailing Address - Street 1:2315 RUTH HENTZ AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-2260
Mailing Address - Country:US
Mailing Address - Phone:850-630-5402
Mailing Address - Fax:
Practice Address - Street 1:2315 RUTH HENTZ AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2260
Practice Address - Country:US
Practice Address - Phone:850-630-5402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-10
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0000000000Medicaid
FL0000000000OtherBCBS PROVIDER #
FL0000000000OtherTRICARE PROVIDER #
FL0000000000OtherBCBS PROVIDER #