Healthcare Provider Details

I. General information

NPI: 1891949707
Provider Name (Legal Business Name): KINETIC KIDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 08/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 EUCLID AVE
CHARLOTTE NC
28203-4520
US

IV. Provider business mailing address

9611 BROOKDALE DR SUITE 100-122
CHARLOTTE NC
28215-8719
US

V. Phone/Fax

Practice location:
  • Phone: 704-807-5699
  • Fax: 704-631-4574
Mailing address:
  • Phone: 704-807-5699
  • Fax: 704-631-4574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QA3000X
TaxonomyAugmentative Communication Clinic/Center
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number StateNC
# 7
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNC
# 8
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNC
# 9
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number StateNC
# 10
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number StateNC
# 11
Primary TaxonomyY
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number StateNC

VIII. Authorized Official

Name: MRS. TIFFANI S. BACON
Title or Position: CO-FOUNDER & PHYSICAL THERAPIST
Credential: PT, MPT
Phone: 704-807-5699