Organization
DOTHAN BRACE SHOP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. WILLIS H SMITHERMAN CPO (PRESIDENT)
(334) 792-4330
Entity
Organization
Contact information
Practice address
1240 E MAIN ST, DOTHAN, AL 36301-1732
(334) 792-4330
(334) 794-6741
Mailing address
1240 E MAIN ST, DOTHAN, AL 36301-1732
(334) 792-4330
(334) 794-6741
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
172
AL
335E00000X
Prosthetic/Orthotic Supplier
001
AL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000040862A
—
GA
01
—
000040862B
MEDICAID
GA
05
—
000050220
—
AL
01
—
51050220
BCBS
—
Enumeration date
07/28/2005
Last updated
09/05/2012
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