Healthcare Provider Details

I. General information

NPI: 1275003196
Provider Name (Legal Business Name): RICARDO E NELSON LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 N KINGS HWY
MYRTLE BEACH SC
29577-2558
US

IV. Provider business mailing address

601 HINSON DR APT 1038
MYRTLE BEACH SC
29579-4467
US

V. Phone/Fax

Practice location:
  • Phone: 843-692-9243
  • Fax:
Mailing address:
  • Phone: 843-693-5014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8768
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: