Provider Demographics
NPI:1821022088
Name:SUSAN Y PELLETIER
Entity Type:Organization
Organization Name:SUSAN Y PELLETIER
Other - Org Name:THE BRACE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:Y
Authorized Official - Last Name:PELLETIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-267-0909
Mailing Address - Street 1:1600 CENTRAL DR
Mailing Address - Street 2:SUITE 157
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76022-6000
Mailing Address - Country:US
Mailing Address - Phone:817-267-0909
Mailing Address - Fax:817-283-1868
Practice Address - Street 1:1600 CENTRAL DR
Practice Address - Street 2:SUITE 157
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76022-6000
Practice Address - Country:US
Practice Address - Phone:817-267-0909
Practice Address - Fax:817-283-1868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2013-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10020974Medicaid
TX10020974Medicaid