Provider Demographics
NPI:1861813867
Name:CAROLINA ORTHOTICS AND PROSTHETICS LLC
Entity Type:Organization
Organization Name:CAROLINA ORTHOTICS AND PROSTHETICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-577-9577
Mailing Address - Street 1:4975 LACROSS RD STE 314
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6531
Mailing Address - Country:US
Mailing Address - Phone:843-577-9577
Mailing Address - Fax:843-718-1438
Practice Address - Street 1:1455 HARDEN STREET EXT
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1755
Practice Address - Country:US
Practice Address - Phone:803-799-5063
Practice Address - Fax:803-252-0872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-18
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0213040004Medicare NSC