MEDICARE: CAROLINA ORTHOTICS AND PROSTHETICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104801125
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA ORTHOTICS AND PROSTHETICS LLC

Provider Business Mailing Address
First Line	:	4975 LACROSS RD STE 314
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-6531
Country	:	US
Telephone Number	:	843-577-9577
Fax Number	:	843-718-1438

Provider Business Practice Location Address
First Line	:	3465 W MONTAGUE AVE STE 101
Second Line	:
City	:	N CHARLESTON
State	:	SC
Zip	:	29418-5938
Country	:	US
Telephone Number	:	843-577-9577
Fax Number	:	843-577-9574

Authorized Official
Title or Position	:	COO
Name	:	DAVID VICK
Credential	:
Telephone Number	:	843-577-9577

Provider Enumeration Date	:	12/13/2005
Last Update Date	:	02/23/2022

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