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General NPI Number Information
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NPI Number | 1174043558
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Entity Type | Organization
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Legal Business Name | ROYAL IVEY WELLNESS, INC.
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Dates
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Enumeration Date | 06/26/2017
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Last Update Date | 06/26/2017
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Provider Practice Location Address
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Address Line | 2712 MIDDLEBURG DR STE 206
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City | COLUMBIA
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State | SC
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Zip | 29204-2415
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Country | US
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Telephone | 803-757-4325
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Fax |
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Provider Business Mailing Address
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Address Line | 2712 MIDDLEBURG DR STE 206
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City | COLUMBIA
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State | SC
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Zip | 29204-2415
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Country | US
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Telephone | 803-757-4325
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Fax |
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Authorized Official
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Title or Position | COUNSELOR/OWNER
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Name | KEYSHA REYNOLDS
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Credential | NCC, LPC
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Telephone | 803-747-4325
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 6380
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License Number State | SC
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