MEDICARE: CAROLINA ORTHOTICS AND PROSTHETICS

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	:	1962808006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA ORTHOTICS AND PROSTHETICS

Provider Business Mailing Address
First Line	:	3801 W MONTAGUE AVE
Second Line	:	STE 100
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29418-5938
Country	:	US
Telephone Number	:	843-577-9577
Fax Number	:	843-718-1438

Provider Business Practice Location Address
First Line	:	1097B COOK RD
Second Line	:
City	:	ORANGEBURG
State	:	SC
Zip	:	29118-8209
Country	:	US
Telephone Number	:	803-937-5456
Fax Number	:	803-937-5460

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLARENCE R HOOPER JR.
Credential	:	CPO
Telephone Number	:	843-577-9577

Provider Enumeration Date	:	11/18/2014
Last Update Date	:	06/21/2017

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Practice Location Address:

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Practice Location Address:

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Practice Location Address:

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1881138378 — MRS. ASHLEY MEADOR BRYAN PA
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