Healthcare Provider Details

I. General information

NPI: 1992577498
Provider Name (Legal Business Name): KENNETH NIEVES LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 SUMTER ST
COLUMBIA SC
29201-2501
US

IV. Provider business mailing address

1825 SUMTER ST
COLUMBIA SC
29201-2501
US

V. Phone/Fax

Practice location:
  • Phone: 803-806-8889
  • Fax: 803-806-8893
Mailing address:
  • Phone: 803-806-8889
  • Fax: 803-806-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12143
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: