Provider Demographics
NPI:1902156474
Name:KINETIC SPINE & SPORTS
Entity type:Organization
Organization Name:KINETIC SPINE & SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DANIELEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-849-0344
Mailing Address - Street 1:1928 WEDDINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEDDINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28104-8318
Mailing Address - Country:US
Mailing Address - Phone:704-849-0344
Mailing Address - Fax:704-849-0521
Practice Address - Street 1:1928 WEDDINGTON RD
Practice Address - Street 2:
Practice Address - City:WEDDINGTON
Practice Address - State:NC
Practice Address - Zip Code:28104-8318
Practice Address - Country:US
Practice Address - Phone:704-849-0344
Practice Address - Fax:704-849-0521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4183111N00000X
NC3711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH4183Medicaid