Healthcare Provider Details

I. General information

NPI: 1932421385
Provider Name (Legal Business Name): CAROLINA PODIATRY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2502 BROAD ST
CAMDEN SC
29020
US

IV. Provider business mailing address

2604 BROAD ST
CAMDEN SC
29020-2240
US

V. Phone/Fax

Practice location:
  • Phone: 803-425-5510
  • Fax: 803-432-4776
Mailing address:
  • Phone: 803-425-5510
  • Fax: 803-432-4776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number563
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberDE3794
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number6460510001
License Number StateSC

VIII. Authorized Official

Name: DR. JOHN KSOR
Title or Position: PODIATRIST
Credential: DPM
Phone: 864-494-0534