Organization
BRACE PLACE LTD
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DAN R DESFOSSES DPT (OWNER)
(208) 234-4579
Entity
Organization
Contact information
Practice address
1033 W QUINN RD, POCATELLO, ID 83202-2425
(208) 234-4579
(208) 233-4887
Mailing address
PO BOX 2844, POCATELLO, ID 83206-2844
(208) 234-4579
(208) 233-4887
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010014433
BLUE SHIELD
ID
01
—
8402D
BLUE CROSS
ID
Enumeration date
10/23/2006
Last updated
03/23/2010
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