Provider Demographics
NPI:1407165178
Name:CHARLESTON BRACE COMPANY, LLC
Entity Type:Organization
Organization Name:CHARLESTON BRACE COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-871-0600
Mailing Address - Street 1:3489 LADSON RD STE C
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4330
Mailing Address - Country:US
Mailing Address - Phone:843-871-0600
Mailing Address - Fax:843-871-6510
Practice Address - Street 1:2061 HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-5017
Practice Address - Country:US
Practice Address - Phone:843-871-0600
Practice Address - Fax:843-871-6510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier