MEDICARE: PURDIEINC, 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	224L00000X	Pedorthist

General Provider Information

NPI Number	:	1902547821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURDIEINC, LLC

Provider Business Mailing Address
First Line	:	655H FAIRVIEW RD # 156
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29680-6706
Country	:	US
Telephone Number	:	843-530-3665
Fax Number	:

Provider Business Practice Location Address
First Line	:	103 E BUTLER RD STE K
Second Line	:
City	:	MAULDIN
State	:	SC
Zip	:	29662-2140
Country	:	US
Telephone Number	:	864-412-8513
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KENDRICK PURDIE
Credential	:
Telephone Number	:	843-530-3665

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	04/05/2022

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