Healthcare Provider Details

I. General information

NPI: 1669859104
Provider Name (Legal Business Name): MOBILE PODIATRY SOUTH CAROLINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 08/30/2020
Certification Date: 08/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SUMMERLEA LN
COLUMBIA SC
29203-3915
US

IV. Provider business mailing address

PO BOX 705
COLUMBIA SC
29202-0705
US

V. Phone/Fax

Practice location:
  • Phone: 803-570-2209
  • Fax: 888-866-4740
Mailing address:
  • Phone: 803-570-2209
  • Fax: 888-866-4740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: KEYOKA SMITH
Title or Position: OWNER
Credential: DPM
Phone: 803-570-2209