Healthcare Provider Details

I. General information

NPI: 1598797045
Provider Name (Legal Business Name): BREAST PROSTHESES & ORTHOTICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/21/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 EDGEMONT AVE
BRISTOL TN
37620-4309
US

IV. Provider business mailing address

1850 EDGEMONT AVE
BRISTOL TN
37620-4309
US

V. Phone/Fax

Practice location:
  • Phone: 423-573-8500
  • Fax: 423-573-8501
Mailing address:
  • Phone: 423-573-8500
  • Fax: 423-573-8501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateVA

VIII. Authorized Official

Name: JANICE MCCRACKEN
Title or Position: OWNER
Credential:
Phone: 423-573-8500