Provider Demographics
NPI:1992531024
Name:FADDEN, MICHAEL BOYRKIN (LMT#11800)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BOYRKIN
Last Name:FADDEN
Suffix:
Gender:M
Credentials:LMT#11800
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 CHICKASAW DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2237
Mailing Address - Country:US
Mailing Address - Phone:803-229-7806
Mailing Address - Fax:
Practice Address - Street 1:650 CHICKASAW DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2237
Practice Address - Country:US
Practice Address - Phone:803-229-7806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-13
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11800225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist