Provider Demographics
NPI:1619061801
Name:EASTERN SHORE ORTHOTICS &
Entity Type:Organization
Organization Name:EASTERN SHORE ORTHOTICS &
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REG COMPLIANCE SPECIALIST III
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGELINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-961-2102
Mailing Address - Street 1:P O BOX 650846
Mailing Address - Street 2:SUITE M
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0846
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2504 DAUPHIN ST
Practice Address - Street 2:SUITE M
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36606-1956
Practice Address - Country:US
Practice Address - Phone:251-471-0071
Practice Address - Fax:251-471-1951
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANGER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-03
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL5098780002Medicare NSC