Provider Demographics
NPI:1780001073
Name:SMOKY MOUNTAIN LIMB AND BRACE
Entity Type:Organization
Organization Name:SMOKY MOUNTAIN LIMB AND BRACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:828-586-8160
Mailing Address - Street 1:PO BOX 223
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-0223
Mailing Address - Country:US
Mailing Address - Phone:828-586-8160
Mailing Address - Fax:828-586-8209
Practice Address - Street 1:256 MARSH LILY DR
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-9477
Practice Address - Country:US
Practice Address - Phone:828-586-8160
Practice Address - Fax:828-586-8209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier