Healthcare Provider Details

I. General information

NPI: 1801393319
Provider Name (Legal Business Name): CAROLINA ORTHOTICS AND PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2018
Last Update Date: 02/23/2022
Certification Date: 02/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 BROAD ST
SUMTER SC
29150-4237
US

IV. Provider business mailing address

4975 LACROSS RD STE 314
NORTH CHARLESTON SC
29406-6531
US

V. Phone/Fax

Practice location:
  • Phone: 803-883-4356
  • Fax: 803-883-4386
Mailing address:
  • Phone: 843-577-9577
  • Fax: 843-718-1438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: DAVID VICK
Title or Position: COO
Credential:
Phone: 843-577-9577