Provider Demographics
NPI:1750388013
Name:FAITH PROSTHEITC-ORTHOTIC SERVICES
Entity type:Organization
Organization Name:FAITH PROSTHEITC-ORTHOTIC SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:B
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD, CPO
Authorized Official - Phone:704-782-0908
Mailing Address - Street 1:303 W ALEXANDER AVE
Mailing Address - Street 2:STE I
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-4078
Mailing Address - Country:US
Mailing Address - Phone:864-229-3299
Mailing Address - Fax:864-229-4491
Practice Address - Street 1:303 W ALEXANDER AVE
Practice Address - Street 2:STE I
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-4078
Practice Address - Country:US
Practice Address - Phone:864-229-3299
Practice Address - Fax:864-229-4491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2063Medicaid
SCDE2063Medicaid