1114013281 NPI number — EASTERN SHORES ORTHOPEDIC BRACE INC

Table of content: (NPI 1114013281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114013281 NPI number — EASTERN SHORES ORTHOPEDIC BRACE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN SHORES ORTHOPEDIC BRACE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114013281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
533 N NOVA ROAD
Provider Second Line Business Mailing Address:
SUITE 104A
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-427-5649
Provider Business Mailing Address Fax Number:
386-427-9018

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
533 N NOVA ROAD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-427-5649
Provider Business Practice Location Address Fax Number:
386-427-9018
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCDADE
Authorized Official First Name:
MARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-427-5649

Provider Taxonomy Codes

  • Taxonomy code: 222Z00000X , with the licence number:  ORT47 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: M2556 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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