Provider Demographics
NPI:1346958626
Name:GRAYBEAL ORTHOPEDIC LLC
Entity Type:Organization
Organization Name:GRAYBEAL ORTHOPEDIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:FANN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:423-975-9884
Mailing Address - Street 1:107 E MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-4631
Mailing Address - Country:US
Mailing Address - Phone:423-975-9884
Mailing Address - Fax:423-975-6678
Practice Address - Street 1:450 PARK PL NW STE 101
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-2127
Practice Address - Country:US
Practice Address - Phone:276-870-9952
Practice Address - Fax:276-444-4679
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAYBEAL ORTHOPEDIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452173Medicaid