Provider Demographics
NPI:1881884971
Name:NORTHERN BRACE COMPANY INC
Entity type:Organization
Organization Name:NORTHERN BRACE COMPANY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-233-4221
Mailing Address - Street 1:610 N MICHIGAN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1078
Mailing Address - Country:US
Mailing Address - Phone:574-233-4221
Mailing Address - Fax:574-233-3966
Practice Address - Street 1:60160 BODNAR BLVD STE. 200
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544
Practice Address - Country:US
Practice Address - Phone:574-256-9008
Practice Address - Fax:574-256-9016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100153030CMedicaid
IN100153030CMedicaid