Healthcare Provider Details

I. General information

NPI: 1508075334
Provider Name (Legal Business Name): KENNETH JOSEPH CORCORAN PT, DPT, SCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2826 RANDOLPH RD
CHARLOTTE NC
28211-1386
US

IV. Provider business mailing address

PO BOX 12512
CHARLOTTE NC
28220-2512
US

V. Phone/Fax

Practice location:
  • Phone: 716-830-4866
  • Fax:
Mailing address:
  • Phone: 716-830-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number029027-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number40QA01368400
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number18323
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: