Healthcare Provider Details

I. General information

NPI: 1427093954
Provider Name (Legal Business Name): CAROLINA PODIATRY GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1190 HIGHWAY 9 BYP W
LANCASTER SC
29720-1709
US

IV. Provider business mailing address

PO BOX 325
LANCASTER SC
29721-0325
US

V. Phone/Fax

Practice location:
  • Phone: 803-285-1411
  • Fax: 803-283-9920
Mailing address:
  • Phone: 803-285-1411
  • Fax: 803-283-9920

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: BRANDON SCOT PERCIVAL
Title or Position: OWNER PODIATRIST
Credential: DPM
Phone: 803-285-1411