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General NPI Number Information
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NPI Number | 1780052258
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Entity Type | Individual
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Provider Name | KEVIN E. BRUEILLY PT, PHD
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Gender | Male
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Dates
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Enumeration Date | 09/14/2015
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Last Update Date | 09/14/2015
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Provider Practice Location Address
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Address Line | 1100 BLYTHE BLVD
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City | CHARLOTTE
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State | NC
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Zip | 28203-5814
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Country | US
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Telephone | 704-355-7760
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Fax |
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Provider Business Mailing Address
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Address Line | 2702 CREEK MANOR DR
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City | WAXHAW
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State | NC
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Zip | 28173-4116
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 14038
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License Number State | NC
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