Provider Demographics
NPI:1952669665
Name:ADVANCED PROSTHETICS OF SPARTANBURG, LLC
Entity Type:Organization
Organization Name:ADVANCED PROSTHETICS OF SPARTANBURG, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGAHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-859-4709
Mailing Address - Street 1:102 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1343
Mailing Address - Country:US
Mailing Address - Phone:864-582-4411
Mailing Address - Fax:864-573-6717
Practice Address - Street 1:102 WILLOW LN
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1343
Practice Address - Country:US
Practice Address - Phone:864-582-4411
Practice Address - Fax:864-573-6717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-01
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
SC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE3522Medicaid
SCDE3522Medicaid