Provider Demographics
NPI:1447496716
Name:CAROLINA PEDORTHIC, LLC
Entity type:Organization
Organization Name:CAROLINA PEDORTHIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:PEDORTHIST
Authorized Official - Phone:864-583-4456
Mailing Address - Street 1:1000 N PINE ST
Mailing Address - Street 2:SUITE 19
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303-3151
Mailing Address - Country:US
Mailing Address - Phone:864-583-4456
Mailing Address - Fax:864-582-2728
Practice Address - Street 1:1000 N PINE ST
Practice Address - Street 2:SUITE 19
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3151
Practice Address - Country:US
Practice Address - Phone:864-583-4456
Practice Address - Fax:864-582-2728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6177630001Medicare NSC