1548660053 NPI number — BERKELEY PROSTHETIC LABORATORY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548660053 NPI number — BERKELEY PROSTHETIC LABORATORY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BERKELEY PROSTHETIC LABORATORY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548660053
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
216 CAROLINA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONCKS CORNER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29461-3785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-761-6411
Provider Business Mailing Address Fax Number:
843-719-1189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
216 CAROLINA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONCKS CORNER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29461-3785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-761-6411
Provider Business Practice Location Address Fax Number:
843-719-1189
Provider Enumeration Date:
09/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
BRANDON
Authorized Official Title or Position:
LAB MANAGER
Authorized Official Telephone Number:
843-761-6411

Provider Taxonomy Codes

  • Taxonomy code: 292200000X , with the licence number:  555 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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