Provider Demographics
NPI:1174544704
Name:GREENVILLE ORTHOTICS AND PROSTHETICS, LLC
Entity type:Organization
Organization Name:GREENVILLE ORTHOTICS AND PROSTHETICS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:RALPH
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:II
Authorized Official - Credentials:CPO
Authorized Official - Phone:864-552-1840
Mailing Address - Street 1:10 EDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4236
Mailing Address - Country:US
Mailing Address - Phone:864-552-1840
Mailing Address - Fax:864-552-1841
Practice Address - Street 1:10 EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4236
Practice Address - Country:US
Practice Address - Phone:864-552-1840
Practice Address - Fax:864-552-1841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7749060001OtherMEDICARE PTAN
SCDE3917Medicaid