Provider Demographics
NPI:1821085366
Name:FLORENCE PODIATRY ASSOCIATES LLC
Entity Type:Organization
Organization Name:FLORENCE PODIATRY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JACOBUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:843-679-9090
Mailing Address - Street 1:510 W CHEVES ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-4448
Mailing Address - Country:US
Mailing Address - Phone:843-679-9090
Mailing Address - Fax:843-679-9080
Practice Address - Street 1:510 W CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-4448
Practice Address - Country:US
Practice Address - Phone:843-679-9090
Practice Address - Fax:843-679-9080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-30
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP9918Medicaid
SCPD5658Medicaid
SCGP9918Medicaid
SCPD5658Medicaid
SC8030Medicare PIN