=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740176387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINETICORE REHAB INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2025
-----------------------------------------------------
Last Update Date | 07/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3006 RAVEN LN
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32539-4368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-401-3144
-----------------------------------------------------
Fax | 239-237-5366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 127
-----------------------------------------------------
City | CRESTVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32536-0127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-401-3144
-----------------------------------------------------
Fax | 239-237-5366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD MEMBER
-----------------------------------------------------
Name | MR. MICHAEL MCNEALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-964-0946
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------