Provider Demographics
NPI:1306498191
Name:MOORE, SHAWN TAYLOR (LMT, MMP, RYT-200)
Entity type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:TAYLOR
Last Name:MOORE
Suffix:
Gender:F
Credentials:LMT, MMP, RYT-200
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:BALLENTINE
Mailing Address - State:SC
Mailing Address - Zip Code:29002-0253
Mailing Address - Country:US
Mailing Address - Phone:803-261-2131
Mailing Address - Fax:
Practice Address - Street 1:1720 DUTCH FORK RD STE D
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-8871
Practice Address - Country:US
Practice Address - Phone:803-261-2131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8625225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist