1346230489 NPI number — MR. KENNETH P STACK PT,MS,CSCS

Table of content: MR. KENNETH P STACK PT,MS,CSCS (NPI 1346230489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346230489 NPI number — MR. KENNETH P STACK PT,MS,CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STACK
Provider First Name:
KENNETH
Provider Middle Name:
P
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT,MS,CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346230489
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1640 EVA MAE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27610-4443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-362-0903
Provider Business Mailing Address Fax Number:
866-434-5096

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 S SAINT MARYS ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27603-1785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-362-0903
Provider Business Practice Location Address Fax Number:
866-434-5096
Provider Enumeration Date:
10/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  8899 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2251G0304X , with the licence number: 8899 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251S0007X , with the licence number: 8899 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2251X0800X , with the licence number: 8899 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11337022 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7212592 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 078V4 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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