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NPI Code Detail

MEDICARE: KINETIC KIDS, INC.

MEDICARE: KINETIC KIDS, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QC1500XCommunity Health Clinic/CenterNC
2261QA3000XAugmentative Communication Clinic/CenterNC
3261QH0100XHealth Service Clinic/CenterNC
4261QH0700XHearing and Speech Clinic/CenterNC
5261QM1300XMulti-Specialty Clinic/CenterNC
6261QR0400XRehabilitation Clinic/CenterNC
7251E00000XHome Health AgencyNC
8261QM0855XAdolescent and Children Mental Health Clinic/CenterNC
9252Y00000XEarly Intervention Provider AgencyNC
10261QD1600XDevelopmental Disabilities Clinic/CenterNC
11261QR0401XComprehensive Outpatient Rehabilitation Facility (CORF)NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1891949707
Entity Type Code : Organization
Provider Name (Legal Business Name) : KINETIC KIDS, INC.
Provider Business Mailing Address
First Line : 9611 BROOKDALE DR
Second Line : SUITE 100-122
City : CHARLOTTE
State : NC
Zip : 28215-8719
Country : US
Telephone Number : 704-807-5699
Fax Number : 704-631-4574
Provider Business Practice Location Address
First Line : 1016 EUCLID AVE
Second Line :
City : CHARLOTTE
State : NC
Zip : 28203-4520
Country : US
Telephone Number : 704-807-5699
Fax Number : 704-631-4574
Authorized Official
Title or Position : CO-FOUNDER & PHYSICAL THERAPIST
Name : MRS. TIFFANI S. BACON
Credential : PT, MPT
Telephone Number : 704-807-5699
Provider Enumeration Date : 11/05/2008
Last Update Date : 08/20/2015

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1235647215 — KELLY LAWLER WEYNAND OTR/L
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1962905745 — BYRON DENARTUS BACON
Practice Location Address:
1016 EUCLID AVE
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28203-4520
Practice Phone: 704-807-5699
Practice Fax: 704-631-4574
1831693498 — MRS. SHYANA MARIA TIRADO
Practice Location Address:
1016 EUCLID AVE
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28203-4520
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Practice Fax: 704-631-4574

Directions to “KINETIC KIDS, INC. ” Practice Location

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