Provider Demographics
NPI:1225460603
Name:INNOVATIVE BRACING CONCEPTS, LLC
Entity Type:Organization
Organization Name:INNOVATIVE BRACING CONCEPTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-381-1511
Mailing Address - Street 1:629 QUINCY ST
Mailing Address - Street 2:#100
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-0200
Mailing Address - Country:US
Mailing Address - Phone:605-716-4922
Mailing Address - Fax:605-716-4947
Practice Address - Street 1:629 QUINCY ST
Practice Address - Street 2:#100
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-0200
Practice Address - Country:US
Practice Address - Phone:605-716-4922
Practice Address - Fax:605-716-4947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6966750001Medicare NSC