Provider Demographics
NPI:1760688410
Name:UPSTATE PEDORTHIC SERVICES INC.
Entity Type:Organization
Organization Name:UPSTATE PEDORTHIC SERVICES INC.
Other - Org Name:UPSTATE PEDORTHIC SERICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:D
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:II
Authorized Official - Credentials:C PED
Authorized Official - Phone:864-848-3300
Mailing Address - Street 1:24 PARKWAY COMMONS WAY
Mailing Address - Street 2:
Mailing Address - City:GREER
Mailing Address - State:SC
Mailing Address - Zip Code:29650-5213
Mailing Address - Country:US
Mailing Address - Phone:864-848-3300
Mailing Address - Fax:864-848-2100
Practice Address - Street 1:24 PARKWAY COMMONS WAY
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-5213
Practice Address - Country:US
Practice Address - Phone:864-848-3300
Practice Address - Fax:864-848-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7702097Medicaid
SCDE1002Medicaid
NC7702097Medicaid