Healthcare Provider Details

I. General information

NPI: 1700386810
Provider Name (Legal Business Name): THE CHARLOTTE ATHLETE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5046 OLD PINEVILLE RD STE 190
CHARLOTTE NC
28217-3035
US

IV. Provider business mailing address

260 W BLAND ST
CHARLOTTE NC
28203-4104
US

V. Phone/Fax

Practice location:
  • Phone: 215-380-3187
  • Fax:
Mailing address:
  • Phone: 215-380-3187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License NumberP16460
License Number StateNC

VIII. Authorized Official

Name: DR. ANDREW KENAS
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT
Phone: 215-380-3187