Provider Demographics
NPI:1669455200
Name:BREATH, KENNETH J (PT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:J
Last Name:BREATH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2237
Mailing Address - Fax:
Practice Address - Street 1:354 COPPERFIELD BLVD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2402
Practice Address - Country:US
Practice Address - Phone:704-262-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP9882225100000X
NC98822251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669455200Medicaid