Provider Demographics
NPI:1710915731
Name:DERA, INC
Entity Type:Organization
Organization Name:DERA, INC
Other - Org Name:FOOT SOLUTIONS-FT WAYNE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:REX
Authorized Official - Last Name:BRUICK
Authorized Official - Suffix:
Authorized Official - Credentials:CPED
Authorized Official - Phone:260-484-8966
Mailing Address - Street 1:513 E COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1215
Mailing Address - Country:US
Mailing Address - Phone:260-484-8966
Mailing Address - Fax:260-484-0508
Practice Address - Street 1:513 E COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1215
Practice Address - Country:US
Practice Address - Phone:260-484-8966
Practice Address - Fax:260-484-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
4845620001Medicare ID - Type Unspecified