Provider Demographics
NPI:1609004803
Name:KIDSCAN THERAPY SERVICES
Entity Type:Organization
Organization Name:KIDSCAN THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMI
Authorized Official - Middle Name:GLYNN
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:336-408-0821
Mailing Address - Street 1:PO BOX 1107
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:NC
Mailing Address - Zip Code:27021-1107
Mailing Address - Country:US
Mailing Address - Phone:336-408-0821
Mailing Address - Fax:336-922-1218
Practice Address - Street 1:523 LYNCHBURG RD
Practice Address - Street 2:
Practice Address - City:PILOT MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:27041-9326
Practice Address - Country:US
Practice Address - Phone:336-408-0821
Practice Address - Fax:336-232-1411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-25
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4662174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7302190Medicaid