=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346958626
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAYBEAL ORTHOPEDIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2022
-----------------------------------------------------
Last Update Date | 11/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 PARK PL NW STE 101
-----------------------------------------------------
City | NORTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24273-2127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-870-9952
-----------------------------------------------------
Fax | 276-444-4679
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 E MYRTLE AVE
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37601-4631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-975-9884
-----------------------------------------------------
Fax | 423-975-6678
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | ADAM LEE FANN
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 423-975-9884
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------