Provider Demographics
NPI:1548308695
Name:PICKERING, ALVIN W (CP,ROF)
Entity type:Individual
Prefix:
First Name:ALVIN
Middle Name:W
Last Name:PICKERING
Suffix:
Gender:M
Credentials:CP,ROF
Other - Prefix:
Other - First Name:ALVIN
Other - Middle Name:W
Other - Last Name:PICKERING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CP,ROF
Mailing Address - Street 1:1884 MIDDLETON ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4687
Mailing Address - Country:US
Mailing Address - Phone:803-387-4107
Mailing Address - Fax:803-534-7280
Practice Address - Street 1:230 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-6022
Practice Address - Country:US
Practice Address - Phone:803-534-6567
Practice Address - Fax:803-534-7280
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCCP1596224P00000X
SCRFO01196225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Not Answered225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE1524Medicaid
SC1275510001Medicare ID - Type UnspecifiedPROSTHETICS,ORTHOTICS