Healthcare Provider Details

I. General information

NPI: 1134155914
Provider Name (Legal Business Name): PALMETTO ORTHO OF CHAS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 05/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 WINGO WAY STE 301
MOUNT PLEASANT SC
29464-1812
US

IV. Provider business mailing address

180 WINGO WAY STE 301
MOUNT PLEASANT SC
29464-1812
US

V. Phone/Fax

Practice location:
  • Phone: 843-884-0302
  • Fax: 843-849-9308
Mailing address:
  • Phone: 843-884-0302
  • Fax: 843-849-9308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number9782
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number9782
License Number StateSC

VIII. Authorized Official

Name: DR. WADDELL H GILMORE III
Title or Position: SENIOR PARTNER
Credential: M.D.
Phone: 843-884-0302