Provider Demographics
NPI:1841898541
Name:MCENTIRE, IVY (MMP)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:MCENTIRE
Suffix:
Gender:F
Credentials:MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BANKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29609-1470
Mailing Address - Country:US
Mailing Address - Phone:864-205-9029
Mailing Address - Fax:
Practice Address - Street 1:3519 PELHAM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4181
Practice Address - Country:US
Practice Address - Phone:864-205-9029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6088225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist