Provider Demographics
NPI:1871519363
Name:SELLECK, MARK T (LPO,CPO)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:T
Last Name:SELLECK
Suffix:
Gender:M
Credentials:LPO,CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4147 SUN N LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SEBRING
Mailing Address - State:FL
Mailing Address - Zip Code:33872-2131
Mailing Address - Country:US
Mailing Address - Phone:305-672-9393
Mailing Address - Fax:305-675-3706
Practice Address - Street 1:3350 NW 2ND AVENUE
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431
Practice Address - Country:US
Practice Address - Phone:561-394-4200
Practice Address - Fax:561-394-4422
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-15
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPOR175335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier