Provider Demographics
NPI:1174043558
Name:ROYAL IVEY WELLNESS, INC.
Entity Type:Organization
Organization Name:ROYAL IVEY WELLNESS, INC.
Other - Org Name:KEYSHA A. REYNOLDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COUNSELOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEYSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:NCC, LPC
Authorized Official - Phone:803-747-4325
Mailing Address - Street 1:2712 MIDDLEBURG DR STE 206
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2415
Mailing Address - Country:US
Mailing Address - Phone:803-757-4325
Mailing Address - Fax:
Practice Address - Street 1:2712 MIDDLEBURG DR STE 206
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2415
Practice Address - Country:US
Practice Address - Phone:803-757-4325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6380251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC1741Medicaid