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General NPI Number Information
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NPI Number | 1720171929
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Entity Type | Organization
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Legal Business Name | CHARLESTON BRACE COMPANY, LLC
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Dates
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Enumeration Date | 10/02/2006
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Last Update Date | 07/15/2024
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Provider Practice Location Address
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Address Line | 9470A HIGHWAY 78
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City | LADSON
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State | SC
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Zip | 29456-3909
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Country | US
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Telephone | 843-871-0600
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Fax | 843-871-6510
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Provider Business Mailing Address
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Address Line | 9470A HIGHWAY 78
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City | LADSON
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State | SC
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Zip | 29456-3909
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Country | US
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Telephone | 843-871-0600
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Fax | 843-871-6510
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Authorized Official
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Title or Position | OWNER
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Name | NATHANIEL ATHA JACKSON
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Credential |
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Telephone | 843-871-0600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 010748453
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License Number State | SC
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