Provider Demographics
NPI:1346230489
Name:STACK, KENNETH P (PT,MS,CSCS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:P
Last Name:STACK
Suffix:
Gender:M
Credentials:PT,MS,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 EVA MAE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-4443
Mailing Address - Country:US
Mailing Address - Phone:800-362-0903
Mailing Address - Fax:866-434-5096
Practice Address - Street 1:115 S SAINT MARYS ST
Practice Address - Street 2:SUITE A
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-1785
Practice Address - Country:US
Practice Address - Phone:800-362-0903
Practice Address - Fax:866-434-5096
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2010-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8899225100000X, 2251G0304X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
11337022OtherCAQH
NC7212592Medicaid
NC078V4OtherBCBS
NC2506881AMedicare PIN