Healthcare Provider Details

I. General information

NPI: 1619061801
Provider Name (Legal Business Name): EASTERN SHORE ORTHOTICS &
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/11/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 DAUPHIN ST SUITE M
MOBILE AL
36606-1956
US

IV. Provider business mailing address

P O BOX 650846 SUITE M
DALLAS TX
75265-0846
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-0071
  • Fax: 251-471-1951
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: GRACE ANGELINE
Title or Position: REG COMPLIANCE SPECIALIST III
Credential:
Phone: 714-961-2102