Provider Demographics
NPI:1497838569
Name:HOLDEN, KENTON JR (PT,MHS,CSCS)
Entity type:Individual
Prefix:MR
First Name:KENTON
Middle Name:
Last Name:HOLDEN
Suffix:JR
Gender:M
Credentials:PT,MHS,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1476 LONG GROVE DR
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1476 LONG GROVE DR
Practice Address - Street 2:SUITE 1
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7571
Practice Address - Country:US
Practice Address - Phone:843-216-3534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2017-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3506225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ336928080Medicare ID - Type Unspecified