Provider Demographics
NPI:1659490860
Name:ACTIVE BRACE AND LIMB
Entity Type:Organization
Organization Name:ACTIVE BRACE AND LIMB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOTIST
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MOSHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-258-8481
Mailing Address - Street 1:5222 N ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-6883
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 S CEDAR STREET
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646
Practice Address - Country:US
Practice Address - Phone:231-258-8481
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier