Provider Demographics
NPI:1700937836
Name:ACTIVE BRACE AND LIMB LLC
Entity Type:Organization
Organization Name:ACTIVE BRACE AND LIMB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PIERCE
Authorized Official - Suffix:
Authorized Official - Credentials:CO
Authorized Official - Phone:231-487-0998
Mailing Address - Street 1:5123 N ROYAL DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-9201
Mailing Address - Country:US
Mailing Address - Phone:231-932-8702
Mailing Address - Fax:231-932-8702
Practice Address - Street 1:2780 CHARLEVOIX AVE
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-8058
Practice Address - Country:US
Practice Address - Phone:231-487-0998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4298510002Medicare NSC