Provider Demographics
NPI:1588856355
Name:HORNE, KEVIN C (CPO)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:C
Last Name:HORNE
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 SAINT LEO STREET
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-3382
Mailing Address - Country:US
Mailing Address - Phone:336-621-9500
Mailing Address - Fax:336-621-0980
Practice Address - Street 1:520 BROOKDALE DR
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-4108
Practice Address - Country:US
Practice Address - Phone:704-872-1037
Practice Address - Fax:704-872-1987
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECP2375174400000X
NC224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795115Medicaid
NC7704084Medicaid
NC7795115Medicaid