Provider Demographics
NPI:1063292597
Name:MADDOX, BAILEY B R (LMT, CLT, CPT-NASM)
Entity type:Individual
Prefix:
First Name:BAILEY
Middle Name:B R
Last Name:MADDOX
Suffix:
Gender:F
Credentials:LMT, CLT, CPT-NASM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1898 CALHOUN ST STE 8
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2650
Mailing Address - Country:US
Mailing Address - Phone:803-200-1916
Mailing Address - Fax:
Practice Address - Street 1:1898 CALHOUN ST STE 8
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2650
Practice Address - Country:US
Practice Address - Phone:803-200-1916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10303225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist