Provider Demographics
NPI:1255026837
Name:MINOR, CANDACE MIYORI
Entity type:Individual
Prefix:MRS
First Name:CANDACE
Middle Name:MIYORI
Last Name:MINOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CANDACE
Other - Middle Name:MIYORI
Other - Last Name:MACON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT #2004
Mailing Address - Street 1:4280 HARLOW BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38701-6604
Mailing Address - Country:US
Mailing Address - Phone:662-390-4920
Mailing Address - Fax:
Practice Address - Street 1:4280 HARLOW BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38701-6604
Practice Address - Country:US
Practice Address - Phone:662-390-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2004225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist