Provider Demographics
NPI:1528331931
Name:UPSTATE CAROLINA MOBILITY
Entity type:Organization
Organization Name:UPSTATE CAROLINA MOBILITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FRANCHISE OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-269-6985
Mailing Address - Street 1:105 LA VON LN
Mailing Address - Street 2:SUITE C
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-2627
Mailing Address - Country:US
Mailing Address - Phone:864-269-6985
Mailing Address - Fax:864-751-1619
Practice Address - Street 1:105 LA VON LN
Practice Address - Street 2:SUITE C
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-2627
Practice Address - Country:US
Practice Address - Phone:864-269-6985
Practice Address - Fax:864-751-1619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA175832350332B00000X
SC039183613332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies