Healthcare Provider Details

I. General information

NPI: 1578798567
Provider Name (Legal Business Name): BRISTOL ORTHOTICS & PROSTHETICS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 04/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 SHORT ST SUITE 5
POUNDING MILL VA
24637-4278
US

IV. Provider business mailing address

553 HIGHWAY 126
BRISTOL TN
37620-1685
US

V. Phone/Fax

Practice location:
  • Phone: 276-963-7786
  • Fax: 276-963-1187
Mailing address:
  • Phone: 423-968-4442
  • Fax: 423-968-4777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberPRO0000000023
License Number StateTN

VIII. Authorized Official

Name: JOSHUA C GRAYBEAL
Title or Position: CP
Credential:
Phone: 423-968-4442