Healthcare Provider Details

I. General information

NPI: 1851843296
Provider Name (Legal Business Name): LANDMARK BRACING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 4J CT UNIT C
GILLETTE WY
82716-4130
US

IV. Provider business mailing address

PO BOX 1790
DOUGLAS WY
82633-1790
US

V. Phone/Fax

Practice location:
  • Phone: 307-686-2569
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: CHARLES MAGUS
Title or Position: TREASURER
Credential:
Phone: 307-358-9464