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

General Provider Information

NPI Number	:	1588085583
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	:	1294 PROFESSIONAL DR
Second Line	:	SUITE B
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5753
Country	:	US
Telephone Number	:	843-497-9558
Fax Number	:	843-497-9130

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

Provider Enumeration Date	:	12/18/2013
Last Update Date	:	02/23/2022

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