Provider Demographics
NPI:1972747855
Name:CAROLINA ORTHOTICS AND PROSTHETICS OF MYRTLE BEACH LLC
Entity Type:Organization
Organization Name:CAROLINA ORTHOTICS AND PROSTHETICS OF MYRTLE BEACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C.
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:JR
Authorized Official - Credentials:CPO
Authorized Official - Phone:843-577-9577
Mailing Address - Street 1:11945 GRANDHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-8091
Mailing Address - Country:US
Mailing Address - Phone:843-651-5347
Mailing Address - Fax:843-651-3451
Practice Address - Street 1:285 MEETING ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1550
Practice Address - Country:US
Practice Address - Phone:843-577-9577
Practice Address - Fax:843-577-9574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2909Medicaid