Provider Demographics
NPI:1518142215
Name:ROOT, MARK (CFO COF)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ROOT
Suffix:
Gender:M
Credentials:CFO COF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 HAMPTON LEAS LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209-1900
Mailing Address - Country:US
Mailing Address - Phone:803-960-0952
Mailing Address - Fax:803-776-6639
Practice Address - Street 1:5950 HAMPTON LEAS LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1900
Practice Address - Country:US
Practice Address - Phone:803-960-0952
Practice Address - Fax:803-776-6639
Is Sole Proprietor?:No
Enumeration Date:2008-01-01
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter