Provider Demographics
NPI:1396930293
Name:THE BRACE SHOPPE INC.
Entity type:Organization
Organization Name:THE BRACE SHOPPE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCO
Authorized Official - Phone:304-638-3128
Mailing Address - Street 1:300 WOOD MIST LN
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN INN
Mailing Address - State:SC
Mailing Address - Zip Code:29644-9273
Mailing Address - Country:US
Mailing Address - Phone:304-638-3128
Mailing Address - Fax:304-638-3128
Practice Address - Street 1:300 WOOD MIST LN
Practice Address - Street 2:
Practice Address - City:FOUNTAIN INN
Practice Address - State:SC
Practice Address - Zip Code:29644-9273
Practice Address - Country:US
Practice Address - Phone:304-638-3128
Practice Address - Fax:304-638-3128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNORT0000000095335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90012089Medicaid
WV3810004179Medicaid
OH2609216Medicaid
KY90012089Medicaid