Healthcare Provider Details

I. General information

NPI: 1154486025
Provider Name (Legal Business Name): RAPHA FAMILY FOOTCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 09/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 CARN ST
WALTERBORO SC
29488-4322
US

IV. Provider business mailing address

PO BOX 1633
WALTERBORO SC
29488-0016
US

V. Phone/Fax

Practice location:
  • Phone: 843-549-6271
  • Fax: 843-542-9030
Mailing address:
  • Phone: 843-549-6271
  • Fax: 843-542-9030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number123
License Number StateSC

VIII. Authorized Official

Name: DR. BEULAH M. BROOKS
Title or Position: PODIATRIST
Credential: DPM
Phone: 843-549-6271