Healthcare Provider Details

I. General information

NPI: 1871765883
Provider Name (Legal Business Name): ANDERSON BRACE & LIMB PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 06/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E PARKVIEW ST
DYERSBURG TN
38024-3110
US

IV. Provider business mailing address

300 E PARKVIEW ST
DYERSBURG TN
38024-3110
US

V. Phone/Fax

Practice location:
  • Phone: 731-286-6006
  • Fax: 731-286-5570
Mailing address:
  • Phone: 731-286-6006
  • Fax: 731-286-5570

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberORT0000000109
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPRO0000000087
License Number StateTN

VIII. Authorized Official

Name: MR. MARK WESLEY ANDERSON
Title or Position: OWNER/CERTIFIED PROSTHETIST ORTHOTI
Credential: CPO
Phone: 731-286-6006