Healthcare Provider Details

I. General information

NPI: 1689588626
Provider Name (Legal Business Name): KEVIN ALEXANDER CALDWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 EXECUTIVE AVE
MYRTLE BEACH SC
29577-6501
US

IV. Provider business mailing address

4600 MONTGOMERY RD STE 400
CINCINNATI OH
45212-2600
US

V. Phone/Fax

Practice location:
  • Phone: 843-712-7316
  • Fax: 843-945-1022
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADC-IP3179
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: