Provider Demographics
NPI:1003864257
Name:ADVANTAGE O & P
Entity Type:Organization
Organization Name:ADVANTAGE O & P
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:K
Authorized Official - Last Name:SELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-669-0000
Mailing Address - Street 1:PO BOX 12448
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29504-2448
Mailing Address - Country:US
Mailing Address - Phone:843-669-0000
Mailing Address - Fax:843-669-4729
Practice Address - Street 1:2295 S IRBY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29505-3424
Practice Address - Country:US
Practice Address - Phone:843-673-9998
Practice Address - Fax:843-669-4729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2592Medicaid
SCDE2592Medicaid