Healthcare Provider Details

I. General information

NPI: 1518142215
Provider Name (Legal Business Name): MARK ROOT CFO COF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2008
Last Update Date: 01/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5950 HAMPTON LEAS LN
COLUMBIA SC
29209-1900
US

IV. Provider business mailing address

5950 HAMPTON LEAS LN
COLUMBIA SC
29209-1900
US

V. Phone/Fax

Practice location:
  • Phone: 803-960-0952
  • Fax: 803-776-6639
Mailing address:
  • Phone: 803-960-0952
  • Fax: 803-776-6639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: