=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700937836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACTIVE BRACE AND LIMB LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 12/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2780 CHARLEVOIX AVE
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-8058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-487-0998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5123 N ROYAL DR
-----------------------------------------------------
City | TRAVERSE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49684-9201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-932-8702
-----------------------------------------------------
Fax | 231-932-8702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO OWNER
-----------------------------------------------------
Name | JERRY ALLEN PIERCE
-----------------------------------------------------
Credential | CO
-----------------------------------------------------
Telephone | 231-487-0998
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------