Healthcare Provider Details

I. General information

NPI: 1649689969
Provider Name (Legal Business Name): KEVIN PRIME DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2014
Last Update Date: 12/17/2019
Certification Date: 12/17/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 GROCE RD
LYMAN SC
29365-1631
US

IV. Provider business mailing address

12 GROCE RD
LYMAN SC
29365-1631
US

V. Phone/Fax

Practice location:
  • Phone: 704-473-4653
  • Fax: 864-439-1346
Mailing address:
  • Phone: 864-439-1345
  • Fax: 864-439-1346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4504
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4379
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: