Provider Demographics
NPI:1720171929
Name:CHARLESTON BRACE CO, LLC
Entity Type:Organization
Organization Name:CHARLESTON BRACE CO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:CO, CPED
Authorized Official - Phone:843-571-4646
Mailing Address - Street 1:3489 LADSON RD STE C
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-4330
Mailing Address - Country:US
Mailing Address - Phone:843-871-0600
Mailing Address - Fax:843-871-6510
Practice Address - Street 1:3489 LADSON RD STE C
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-4330
Practice Address - Country:US
Practice Address - Phone:843-871-0600
Practice Address - Fax:843-871-6510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC010748453335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5476270001Medicare NSC