Provider Demographics
NPI:1063825412
Name:STRONG STANCE ORTHOTICS & FITNESS
Entity Type:Organization
Organization Name:STRONG STANCE ORTHOTICS & FITNESS
Other - Org Name:PROGRESSIVE ATHLETIC DEVELOPMENT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEDRICK
Authorized Official - Middle Name:LANARD
Authorized Official - Last Name:AGEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-249-9793
Mailing Address - Street 1:495 HEATHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244-3221
Mailing Address - Country:US
Mailing Address - Phone:205-249-9793
Mailing Address - Fax:
Practice Address - Street 1:1529 BESSEMER RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35208-4016
Practice Address - Country:US
Practice Address - Phone:205-249-9793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL583174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty