1578798567 NPI number — BRISTOL ORTHOTICS & PROSTHETICS, INC

Table of content: (NPI 1578798567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578798567 NPI number — BRISTOL ORTHOTICS & PROSTHETICS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRISTOL ORTHOTICS & PROSTHETICS, 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:
1578798567
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
553 HIGHWAY 126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRISTOL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37620-1685
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-968-4442
Provider Business Mailing Address Fax Number:
423-968-4777

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
113 SHORT ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
POUNDING MILL
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24637-4278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-963-7786
Provider Business Practice Location Address Fax Number:
276-963-1187
Provider Enumeration Date:
05/20/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GRAYBEAL
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CP
Authorized Official Telephone Number:
423-968-4442

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  PRO0000000023 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009190881 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0009791 . This is a "BLUR CROSS BLUE SHIELD" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 009113827 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3539103 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1131621 . This is a "UNITED MINE WORKERS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 141558 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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