Provider Demographics
NPI:1629130760
Name:PERFORMANCE BRACING & ORTHOTICS, LLC
Entity Type:Organization
Organization Name:PERFORMANCE BRACING & ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:P
Authorized Official - Last Name:HUBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-872-3535
Mailing Address - Street 1:443 N NEW BALLAS RD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6800
Mailing Address - Country:US
Mailing Address - Phone:314-872-3535
Mailing Address - Fax:314-787-0233
Practice Address - Street 1:845 N NEW BALLAS CT
Practice Address - Street 2:SUITE 120
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7134
Practice Address - Country:US
Practice Address - Phone:314-872-3535
Practice Address - Fax:314-787-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO625893706Medicaid
MO625893706Medicaid