Provider Demographics
NPI:1538211339
Name:DIAGNOSTIC & COMPREHENSIVE FOOT CARE
Entity type:Organization
Organization Name:DIAGNOSTIC & COMPREHENSIVE FOOT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:803-790-7200
Mailing Address - Street 1:6941 N TRENHOLM RD STE H1
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-1715
Mailing Address - Country:US
Mailing Address - Phone:803-790-7200
Mailing Address - Fax:803-790-0520
Practice Address - Street 1:6941 N TRENHOLM RD
Practice Address - Street 2:H1
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-1715
Practice Address - Country:US
Practice Address - Phone:803-790-7200
Practice Address - Fax:803-790-0520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
SCSC519213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4886890001Medicare NSC