Provider Demographics
NPI:1639541162
Name:BAILES, ANTHONY (LAC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:BAILES
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:684 LALTON DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-7872
Mailing Address - Country:US
Mailing Address - Phone:512-569-2398
Mailing Address - Fax:
Practice Address - Street 1:1110 LONDON ST
Practice Address - Street 2:SUITE 105
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5799
Practice Address - Country:US
Practice Address - Phone:843-742-6040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-23
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC245171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist