Provider Demographics
NPI:1831457142
Name:KINETIC KIDS, LLC
Entity Type:Organization
Organization Name:KINETIC KIDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:269-381-1880
Mailing Address - Street 1:540 EAST MILHAM
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002
Mailing Address - Country:US
Mailing Address - Phone:269-381-1880
Mailing Address - Fax:269-381-1850
Practice Address - Street 1:540 EAST MILHAM
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002
Practice Address - Country:US
Practice Address - Phone:269-381-1880
Practice Address - Fax:269-381-1850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004171225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4719045Medicaid
MI0P08850Medicare UPIN