Provider Demographics
NPI:1215108196
Name:AMPUTEE AND BRACE CLNC IN
Entity type:Organization
Organization Name:AMPUTEE AND BRACE CLNC IN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:GUNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-545-9999
Mailing Address - Street 1:PO BOX 708
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-0708
Mailing Address - Country:US
Mailing Address - Phone:843-545-9999
Mailing Address - Fax:
Practice Address - Street 1:605 N FRASER ST
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3265
Practice Address - Country:US
Practice Address - Phone:843-545-9999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-18
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1267970001Medicare NSC