Provider Demographics
NPI:1326826421
Name:MIRACLE BRACE LLC
Entity Type:Organization
Organization Name:MIRACLE BRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-805-5226
Mailing Address - Street 1:4676 COMMERCIAL ST SE STE 81
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1902
Mailing Address - Country:US
Mailing Address - Phone:833-432-5639
Mailing Address - Fax:
Practice Address - Street 1:2355 STATE ST STE 101
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4541
Practice Address - Country:US
Practice Address - Phone:833-432-5639
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-19
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies