Provider Demographics
NPI:1730366485
Name:CONCOURSE BRACING & ORTHOTICS
Entity type:Organization
Organization Name:CONCOURSE BRACING & ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATTI
Authorized Official - Middle Name:A
Authorized Official - Last Name:SELDERS-ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-518-9533
Mailing Address - Street 1:PO BOX 420508
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-0508
Mailing Address - Country:US
Mailing Address - Phone:678-518-9533
Mailing Address - Fax:678-518-9583
Practice Address - Street 1:2183 RAMBLEWOOD CIR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3644
Practice Address - Country:US
Practice Address - Phone:678-518-9533
Practice Address - Fax:678-518-9583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52188205 001OtherBLUECROSS BLUESHIELD