Provider Demographics
NPI:1972148088
Name:REYNOLDS, NATHAN (LMT)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:REYNOLDS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3071 HIGHWAY 21 STE 105
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-7206
Mailing Address - Country:US
Mailing Address - Phone:803-547-6634
Mailing Address - Fax:
Practice Address - Street 1:3071 HIGHWAY 21 STE 105
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-7206
Practice Address - Country:US
Practice Address - Phone:803-547-6634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11748225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty