Provider Demographics
NPI:1417962275
Name:CENTRAL BRACE COMPANY
Entity Type:Organization
Organization Name:CENTRAL BRACE COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:WESTON
Authorized Official - Last Name:BENEDICT
Authorized Official - Suffix:
Authorized Official - Credentials:BOCO, C PED
Authorized Official - Phone:573-874-0321
Mailing Address - Street 1:404 PORTLAND ST
Mailing Address - Street 2:REAR ENTRANCE EYE RESEARCH FOUNDATION
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6506
Mailing Address - Country:US
Mailing Address - Phone:573-874-0321
Mailing Address - Fax:573-874-2003
Practice Address - Street 1:404 PORTLAND ST
Practice Address - Street 2:REAR ENTRANCE EYE RESEARCH FOUNDATION
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6506
Practice Address - Country:US
Practice Address - Phone:573-874-0321
Practice Address - Fax:573-874-2003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO628004400Medicaid
MO628004400Medicaid