Healthcare Provider Details

I. General information

NPI: 1215863485
Provider Name (Legal Business Name): KELLEY SUTTON LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2026
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

933 BROADWAY ST
MYRTLE BEACH SC
29577-3718
US

IV. Provider business mailing address

933 BROADWAY ST
MYRTLE BEACH SC
29577-3718
US

V. Phone/Fax

Practice location:
  • Phone: 910-380-2230
  • Fax:
Mailing address:
  • Phone: 910-380-2230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number8401
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: