Basic Information
| Provider Information | |||||||||
| NPI: | 1518930817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERCIVAL | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | SCOT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.M. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 325 | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297210325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032851411 | ||||||||
| FaxNumber: | 8032839920 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 HIGHWAY 9 BYP W | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | SC | ||||||||
| PostalCode: | 297201709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032851411 | ||||||||
| FaxNumber: | 8032839920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2006 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 536 | SC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | PD5364 | 05 | SC | MEDICAID | 480028265 | 01 | SC | RAILROAD MEDICARE | OTHER |