Provider Demographics
NPI:1720379415
Name:KINETICWISE
Entity Type:Organization
Organization Name:KINETICWISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:970-682-2038
Mailing Address - Street 1:2601 S LEMAY AVE
Mailing Address - Street 2:SUITE 35
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-2295
Mailing Address - Country:US
Mailing Address - Phone:970-682-2038
Mailing Address - Fax:
Practice Address - Street 1:2601 S LEMAY AVE
Practice Address - Street 2:SUITE 35
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-2295
Practice Address - Country:US
Practice Address - Phone:970-682-2038
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty