Healthcare Provider Details

I. General information

NPI: 1972960722
Provider Name (Legal Business Name): SANDHILLS FOOT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 CLEMSON RD
COLUMBIA SC
29229-7832
US

IV. Provider business mailing address

1821 CLEMSON RD
COLUMBIA SC
29229-7832
US

V. Phone/Fax

Practice location:
  • Phone: 803-788-6400
  • Fax:
Mailing address:
  • Phone: 803-788-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number00627
License Number StateSC

VIII. Authorized Official

Name: DR. MICHAEL THACKER
Title or Position: SOLE MEMBER
Credential: DPM
Phone: 803-788-6400