MEDICARE: MR. KEVIN MICHAEL DEIGHAN LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	6146	SC

General Provider Information

NPI Number	:	1902145865
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KEVIN MICHAEL DEIGHAN LMT

Provider Business Mailing Address
First Line	:	4736 HIGHWAY 17 BYP S
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-5616
Country	:	US
Telephone Number	:	843-444-9355
Fax Number	:	843-294-0019

Provider Business Practice Location Address
First Line	:	4736 HIGHWAY 17 BYP S
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29588-5616
Country	:	US
Telephone Number	:	843-444-9355
Fax Number	:	843-294-0019

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2013
Last Update Date	:	02/12/2013

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