Provider Demographics
NPI:1275564429
Name:SPORES, KENNETH (PT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:SPORES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:304 W WEAVER ST
Practice Address - Street 2:STE 103
Practice Address - City:CARRBORO
Practice Address - State:NC
Practice Address - Zip Code:27510-2084
Practice Address - Country:US
Practice Address - Phone:919-942-0240
Practice Address - Fax:919-942-0280
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC82622251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic