1376891119 NPI number — SUMTER PROSTHETICS & ORTHOTICS LLC

Table of content: (NPI 1376891119)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376891119 NPI number — SUMTER PROSTHETICS & ORTHOTICS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUMTER PROSTHETICS & ORTHOTICS 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:
6
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:
1376891119
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 W MONTAGUE AVE STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
N CHARLESTON
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29418-5938
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-577-9577
Provider Business Mailing Address Fax Number:
843-718-1438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 A BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-4146
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-883-4356
Provider Business Practice Location Address Fax Number:
803-883-4386
Provider Enumeration Date:
08/28/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HOOPER
Authorized Official First Name:
C
Authorized Official Middle Name:
RALPH
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
843-577-9577

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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