Provider Demographics
NPI:1265813968
Name:CHARLESTON BRACE COMPANY, LLC
Entity Type:Organization
Organization Name:CHARLESTON BRACE COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CO, BOCPO, CPED
Authorized Official - Phone:843-871-0600
Mailing Address - Street 1:1220 HOSPITAL DR # B
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3678
Mailing Address - Country:US
Mailing Address - Phone:843-849-1930
Mailing Address - Fax:843-849-1932
Practice Address - Street 1:1220-B HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3678
Practice Address - Country:US
Practice Address - Phone:843-849-1930
Practice Address - Fax:843-849-1932
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLESTON BRACE COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-18
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC010116126335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier