Provider Demographics
NPI:1750678033
Name:GREAT SOUTH BAY BRACING LLC
Entity Type:Organization
Organization Name:GREAT SOUTH BAY BRACING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONNAMARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-714-4770
Mailing Address - Street 1:32 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2621
Mailing Address - Country:US
Mailing Address - Phone:631-714-4770
Mailing Address - Fax:
Practice Address - Street 1:32 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2621
Practice Address - Country:US
Practice Address - Phone:631-714-4770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies