Provider Demographics
NPI:1548660053
Name:BERKELEY PROSTHETIC LABORATORY LLC
Entity type:Organization
Organization Name:BERKELEY PROSTHETIC LABORATORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LAB MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-761-6411
Mailing Address - Street 1:216 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:MONCKS CORNER
Mailing Address - State:SC
Mailing Address - Zip Code:29461-3785
Mailing Address - Country:US
Mailing Address - Phone:843-761-6411
Mailing Address - Fax:843-719-1189
Practice Address - Street 1:216 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-3785
Practice Address - Country:US
Practice Address - Phone:843-761-6411
Practice Address - Fax:843-719-1189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-03
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC555292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory