Healthcare Provider Details

I. General information

NPI: 1114013281
Provider Name (Legal Business Name): EASTERN SHORES ORTHOPEDIC BRACE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 N NOVA ROAD SUITE 104
ORMOND BEACH FL
32174
US

IV. Provider business mailing address

533 N NOVA ROAD SUITE 104A
ORMOND BEACH FL
32174
US

V. Phone/Fax

Practice location:
  • Phone: 386-427-5649
  • Fax: 386-427-9018
Mailing address:
  • Phone: 386-427-5649
  • Fax: 386-427-9018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberORT47
License Number StateFL

VIII. Authorized Official

Name: MRS. MARY M MCDADE
Title or Position: OWNER
Credential: CO
Phone: 386-427-5649