Provider Demographics
NPI:1720442957
Name:KENNON, MARK (LMT, HEALTH COACH)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KENNON
Suffix:
Gender:M
Credentials:LMT, HEALTH COACH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 LONG POINT RD
Mailing Address - Street 2:STE 403
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-8297
Mailing Address - Country:US
Mailing Address - Phone:843-514-6731
Mailing Address - Fax:
Practice Address - Street 1:721 LONG POINT RD
Practice Address - Street 2:STE 403
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-8297
Practice Address - Country:US
Practice Address - Phone:843-514-6731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7246225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist