Provider Demographics
NPI:1215448824
Name:FULL STRIDE PROVIDERS
Entity type:Organization
Organization Name:FULL STRIDE PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JC
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-532-6020
Mailing Address - Street 1:513 EAST MAIN STREET
Mailing Address - Street 2:P.O. BOX 1695
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 VILLA LN UNIT F
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-6569
Practice Address - Country:US
Practice Address - Phone:434-532-6020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies