Provider Demographics
NPI:1679761126
Name:SPORTSBRACE DBA
Entity Type:Organization
Organization Name:SPORTSBRACE DBA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:FUSILLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-424-6100
Mailing Address - Street 1:806 LINDEN AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:806 LINDEN AVE STE 400
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2719
Practice Address - Country:US
Practice Address - Phone:585-424-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies