Provider Demographics
NPI:1720045768
Name:JARED M LEWIS
Entity Type:Organization
Organization Name:JARED M LEWIS
Other - Org Name:J & M BRACING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JARED
Authorized Official - Middle Name:MATHIAS
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:ORTHOTIC FITTER
Authorized Official - Phone:321-632-1116
Mailing Address - Street 1:906 DIXON BLVD
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-6890
Mailing Address - Country:US
Mailing Address - Phone:321-632-1116
Mailing Address - Fax:321-632-4994
Practice Address - Street 1:906 DIXON BLVD
Practice Address - Street 2:
Practice Address - City:COCOA
Practice Address - State:FL
Practice Address - Zip Code:32922-6890
Practice Address - Country:US
Practice Address - Phone:321-632-1116
Practice Address - Fax:321-632-4994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLORF 134335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5395090001Medicare NSC