Basic Information
| Provider Information | |||||||||
| NPI: | 1619235173 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CAROLINA FOOT INSTITUTE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE FOOT INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 718 BROUGHTON ST | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8035312888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 08/31/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RAY | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8035312888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINA FOOT INSTITUTE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DPM | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.