Healthcare Provider Details

I. General information

NPI: 1700937836
Provider Name (Legal Business Name): ACTIVE BRACE AND LIMB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CHARLEVOIX AVE
PETOSKEY MI
49770-8058
US

IV. Provider business mailing address

5123 N ROYAL DR
TRAVERSE CITY MI
49684-9201
US

V. Phone/Fax

Practice location:
  • Phone: 231-487-0998
  • Fax:
Mailing address:
  • Phone: 231-932-8702
  • Fax: 231-932-8702

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: JERRY ALLEN PIERCE
Title or Position: CO OWNER
Credential: CO
Phone: 231-487-0998