Provider Demographics
NPI:1902354053
Name:BERRY'S PROSTHETICS & ORTHOTICS, LLC
Entity Type:Organization
Organization Name:BERRY'S PROSTHETICS & ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:769-251-0555
Mailing Address - Street 1:115 SWINGING BRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BYRAM
Mailing Address - State:MS
Mailing Address - Zip Code:39272-5928
Mailing Address - Country:US
Mailing Address - Phone:769-251-0555
Mailing Address - Fax:769-251-0366
Practice Address - Street 1:115 SWINGING BRIDGE DR
Practice Address - Street 2:
Practice Address - City:BYRAM
Practice Address - State:MS
Practice Address - Zip Code:39272-5928
Practice Address - Country:US
Practice Address - Phone:769-251-0555
Practice Address - Fax:769-251-0366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS7566290001Medicare NSC