Healthcare Provider Details

I. General information

NPI: 1477826071
Provider Name (Legal Business Name): DEEALICE MOTON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 01/09/2025
Certification Date: 01/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6350 WOODSIDE EXECUTIVE CT
AIKEN SC
29803-3825
US

IV. Provider business mailing address

6240 WOODSIDE EXECUTIVE CT
AIKEN SC
29803-3822
US

V. Phone/Fax

Practice location:
  • Phone: 706-951-5812
  • Fax:
Mailing address:
  • Phone: 706-627-6005
  • Fax: 888-807-5411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number9071
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMAS.9071
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number9071
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number9071
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT007357
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number9071
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: