Healthcare Provider Details

I. General information

NPI: 1598128720
Provider Name (Legal Business Name): KACEY OHLEMEYER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date: 06/04/2018
Reactivation Date: 06/14/2018

III. Provider practice location address

2700 S PROVIDENCE RD
WAXHAW NC
28173-6313
US

IV. Provider business mailing address

2700 S PROVIDENCE RD STE 225
WAXHAW NC
28173-6314
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-8778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-6040
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: