Healthcare Provider Details

I. General information

NPI: 1124797410
Provider Name (Legal Business Name): BOB KEOPHAKDY IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W HILL BLVD
CHARLESTON SC
29404-4704
US

IV. Provider business mailing address

PSC 62 BOX 7002
APO AE
09643-0071
US

V. Phone/Fax

Practice location:
  • Phone: 843-963-6880
  • Fax:
Mailing address:
  • Phone: 314-722-8069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: