Provider Demographics
NPI:1174827604
Name:EMBRACE DIABETES FOOTWEAR SOLUTIONS
Entity Type:Organization
Organization Name:EMBRACE DIABETES FOOTWEAR SOLUTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TODDY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-994-0543
Mailing Address - Street 1:982 N COOPER ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-5779
Mailing Address - Country:US
Mailing Address - Phone:817-994-0543
Mailing Address - Fax:
Practice Address - Street 1:982 N COOPER ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-5779
Practice Address - Country:US
Practice Address - Phone:817-994-0543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX651515165OtherMULTIPLE LICENSE STATE OF TEXAS