Healthcare Provider Details

I. General information

NPI: 1124910039
Provider Name (Legal Business Name): KINETIC PEDIATRIC THERAPY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 E ARLINGTON BLVD
GREENVILLE NC
27858-5870
US

IV. Provider business mailing address

1540 E ARLINGTON BLVD
GREENVILLE NC
27858-5870
US

V. Phone/Fax

Practice location:
  • Phone: 252-902-7061
  • Fax: 252-364-2863
Mailing address:
  • Phone: 252-902-7061
  • Fax: 252-364-2863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: CHARLIE DAVID EDWARDS
Title or Position: CO-OWNER
Credential: DPT
Phone: 252-902-7061