Provider Demographics
NPI:1093983215
Name:OTIS BOYD GARDO JR
Entity Type:Organization
Organization Name:OTIS BOYD GARDO JR
Other - Org Name:HIGHLANDS ANAPLASTOLOGY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-232-3008
Mailing Address - Street 1:126 COOL MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:SC
Mailing Address - Zip Code:29673-8941
Mailing Address - Country:US
Mailing Address - Phone:864-232-3008
Mailing Address - Fax:864-845-8556
Practice Address - Street 1:1007 GROVE RD
Practice Address - Street 2:SUITE E
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4630
Practice Address - Country:US
Practice Address - Phone:864-232-3008
Practice Address - Fax:864-845-8556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA530923946BMedicaid
NC7704873Medicaid
SCDE2711Medicaid
SCDE2711Medicaid
=========OtherTRICARE
GA530923946BMedicaid
SC4860940001Medicare NSC