Provider Demographics
NPI:1194041228
Name:ALEXCO, INC.
Entity Type:Organization
Organization Name:ALEXCO, INC.
Other - Org Name:SOUTHERN COMFORT SHOES AND PEDORTHIC SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:706-434-0129
Mailing Address - Street 1:1001 WALTON WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2841
Mailing Address - Country:US
Mailing Address - Phone:706-434-0129
Mailing Address - Fax:706-305-1277
Practice Address - Street 1:1001 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2841
Practice Address - Country:US
Practice Address - Phone:706-434-0129
Practice Address - Fax:706-305-1277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-14
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier