Healthcare Provider Details

I. General information

NPI: 1215831136
Provider Name (Legal Business Name): KEWARREN L ARDREY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14045 BALLANTYNE CORPORATE PL STE 500
CHARLOTTE NC
28277-0805
US

IV. Provider business mailing address

14045 BALLANTYNE CORPORATE PL STE 500
CHARLOTTE NC
28277-0805
US

V. Phone/Fax

Practice location:
  • Phone: 704-325-3632
  • Fax:
Mailing address:
  • Phone: 704-325-3632
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: