Provider Demographics
NPI:1346209202
Name:CAROLINA ORTHOTICS & PROSTHETICS OF MYRTLE BEACH LLC
Entity Type:Organization
Organization Name:CAROLINA ORTHOTICS & PROSTHETICS OF MYRTLE BEACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:843-577-9577
Mailing Address - Street 1:3465 W MONTAGUE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29418-5938
Mailing Address - Country:US
Mailing Address - Phone:843-577-9577
Mailing Address - Fax:843-577-9574
Practice Address - Street 1:9714 N KINGS HWY STE 142
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4047
Practice Address - Country:US
Practice Address - Phone:843-497-9558
Practice Address - Fax:843-497-9130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-20
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE3311Medicaid
SC0213040003Medicare NSC