Healthcare Provider Details

I. General information

NPI: 1730189028
Provider Name (Legal Business Name): DOTHAN BRACE SHOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 E MAIN ST
DOTHAN AL
36301-1732
US

IV. Provider business mailing address

1240 E MAIN ST
DOTHAN AL
36301-1732
US

V. Phone/Fax

Practice location:
  • Phone: 334-792-4330
  • Fax: 334-794-6741
Mailing address:
  • Phone: 334-792-4330
  • Fax: 334-794-6741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number172
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number001
License Number StateAL

VIII. Authorized Official

Name: MR. WILLIS H SMITHERMAN
Title or Position: PRESIDENT
Credential: CPO
Phone: 334-792-4330