Provider Demographics
NPI:1114013281
Name:EASTERN SHORES ORTHOPEDIC BRACE INC
Entity Type:Organization
Organization Name:EASTERN SHORES ORTHOPEDIC BRACE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCDADE
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:386-427-5649
Mailing Address - Street 1:533 N NOVA ROAD
Mailing Address - Street 2:SUITE 104A
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-427-5649
Mailing Address - Fax:386-427-9018
Practice Address - Street 1:533 N NOVA ROAD
Practice Address - Street 2:SUITE 104
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-427-5649
Practice Address - Fax:386-427-9018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORT47222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
M2556OtherBCBS