Healthcare Provider Details

I. General information

NPI: 1093983215
Provider Name (Legal Business Name): OTIS BOYD GARDO JR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 GROVE RD SUITE E
GREENVILLE SC
29605-4630
US

IV. Provider business mailing address

126 COOL MEADOWS DR
PIEDMONT SC
29673-8941
US

V. Phone/Fax

Practice location:
  • Phone: 864-232-3008
  • Fax: 864-845-8556
Mailing address:
  • Phone: 864-232-3008
  • Fax: 864-845-8556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MRS. REBECCA J. GARDO
Title or Position: OFFICE MANAGER
Credential:
Phone: 864-232-3008