Provider Demographics
NPI:1063617629
Name:CHARLESTON BRACE COMPANY, LLC
Entity type:Organization
Organization Name:CHARLESTON BRACE COMPANY, 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:843-542-9000
Mailing Address - Street 1:9470 HIGHWAY 78 # A
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-3909
Mailing Address - Country:US
Mailing Address - Phone:843-871-0600
Mailing Address - Fax:843-871-6510
Practice Address - Street 1:111 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-2911
Practice Address - Country:US
Practice Address - Phone:843-542-9000
Practice Address - Fax:843-542-2612
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLESTON BRACE COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC015090713335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier