Provider Demographics
NPI:1730189028
Name:DOTHAN BRACE SHOP
Entity type:Organization
Organization Name:DOTHAN BRACE SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:H
Authorized Official - Last Name:SMITHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:334-792-4330
Mailing Address - Street 1:1240 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1732
Mailing Address - Country:US
Mailing Address - Phone:334-792-4330
Mailing Address - Fax:334-794-6741
Practice Address - Street 1:1240 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1732
Practice Address - Country:US
Practice Address - Phone:334-792-4330
Practice Address - Fax:334-794-6741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL001335E00000X
AL172332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000040862BOtherMEDICAID
GA000040862AMedicaid
AL000050220Medicaid
51050220OtherBCBS
GA000040862BOtherMEDICAID