Provider Demographics
NPI:1578798567
Name:BRISTOL ORTHOTICS & PROSTHETICS, INC
Entity Type:Organization
Organization Name:BRISTOL ORTHOTICS & PROSTHETICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CP
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GRAYBEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-968-4442
Mailing Address - Street 1:553 HIGHWAY 126
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-1685
Mailing Address - Country:US
Mailing Address - Phone:423-968-4442
Mailing Address - Fax:423-968-4777
Practice Address - Street 1:113 SHORT ST
Practice Address - Street 2:SUITE 5
Practice Address - City:POUNDING MILL
Practice Address - State:VA
Practice Address - Zip Code:24637-4278
Practice Address - Country:US
Practice Address - Phone:276-963-7786
Practice Address - Fax:276-963-1187
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRISTOL ORTHOTICS & PROSTHETICS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-20
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO0000000023335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009190881Medicaid
TN0009791OtherBLUR CROSS BLUE SHIELD
VA009113827Medicaid
TN3539103Medicaid
TN1131621OtherUNITED MINE WORKERS
VA141558OtherANTHEM
TN3539103Medicaid