Provider Demographics
NPI:1174361315
Name:PREMIUM BRACES LLC
Entity type:Organization
Organization Name:PREMIUM BRACES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-215-0644
Mailing Address - Street 1:239 E KINGSBRIDGE RD APT 1E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-4431
Mailing Address - Country:US
Mailing Address - Phone:315-215-0644
Mailing Address - Fax:
Practice Address - Street 1:239 E KINGSBRIDGE RD APT 1E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-4431
Practice Address - Country:US
Practice Address - Phone:347-517-1312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-19
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies