Healthcare Provider Details

I. General information

NPI: 1255425526
Provider Name (Legal Business Name): KINGSPORT BRACE AND LIMB, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 10/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 BROAD ST
KINGSPORT TN
37660-3801
US

IV. Provider business mailing address

921 BROAD ST
KINGSPORT TN
37660-3801
US

V. Phone/Fax

Practice location:
  • Phone: 423-246-3324
  • Fax: 423-246-9176
Mailing address:
  • Phone: 423-246-3324
  • Fax: 423-246-9176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number
License Number State

VIII. Authorized Official

Name: MR. TERRY ALLEN GRAYBEAL
Title or Position: PRESIDENT/CPO
Credential: CPO
Phone: 423-246-3324