Healthcare Provider Details

I. General information

NPI: 1164816211
Provider Name (Legal Business Name): KEYOKA S SMITH DPM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2015
Last Update Date: 08/30/2020
Certification Date: 08/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 N MAIN ST STE 202
COLUMBIA SC
29203-5800
US

IV. Provider business mailing address

PO BOX 705
COLUMBIA SC
29202-0705
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number622
License Number StateSC

VIII. Authorized Official

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