Healthcare Provider Details

I. General information

NPI: 1447389051
Provider Name (Legal Business Name): DPMKISHNRSC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 10/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 LOCKMAN RD
ELGIN SC
29045-8715
US

IV. Provider business mailing address

411 LOCKMAN RD
ELGIN SC
29045-8715
US

V. Phone/Fax

Practice location:
  • Phone: 803-466-0504
  • Fax:
Mailing address:
  • Phone: 803-466-0504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number144
License Number StateSC

VIII. Authorized Official

Name: ROBERT N KISH
Title or Position: OWNER
Credential: DPM
Phone: 803-466-0504