Provider Demographics
NPI:1861534216
Name:MANATEE PROSTHETICS & ORTHOTICS
Entity type:Organization
Organization Name:MANATEE PROSTHETICS & ORTHOTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPO,CP
Authorized Official - Phone:941-747-5407
Mailing Address - Street 1:535 8TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8530
Mailing Address - Country:US
Mailing Address - Phone:941-747-5407
Mailing Address - Fax:941-747-4914
Practice Address - Street 1:535 8TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-8530
Practice Address - Country:US
Practice Address - Phone:941-747-5407
Practice Address - Fax:941-747-4914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR131335E00000X
FLPOR 131332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM2380OtherBC
FL026426100Medicaid
FL026426100Medicaid