Provider Demographics
NPI:1063667434
Name:POTOMAC COBBLER, INC
Entity Type:Organization
Organization Name:POTOMAC COBBLER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TREAS. POTOMAC COBBER, INC
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:SR
Authorized Official - Credentials:BOARD CERTIFIED PEDO
Authorized Official - Phone:703-491-4222
Mailing Address - Street 1:14437 JEFFERSON DAVIS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-2805
Mailing Address - Country:US
Mailing Address - Phone:703-491-4222
Mailing Address - Fax:703-491-1040
Practice Address - Street 1:14437 JEFFERSON DAVIS HIGHWAY
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22191-2805
Practice Address - Country:US
Practice Address - Phone:703-491-4222
Practice Address - Fax:703-491-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1994335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
1163840001Medicare NSC