Provider Demographics
NPI:1649629783
Name:CANTWELL, MCKENZIE
Entity type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:
Last Name:CANTWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 AIKEN ST APT B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29403-5154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1662 SAVANNAH HWY
Practice Address - Street 2:SUITE 315
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-2235
Practice Address - Country:US
Practice Address - Phone:315-921-5400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC221171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist