Provider Demographics
NPI:1891424297
Name:KANEVERSKY, COLTER (ATC)
Entity Type:Individual
Prefix:
First Name:COLTER
Middle Name:
Last Name:KANEVERSKY
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 FORT CONGAREE TRL APT 2637
Mailing Address - Street 2:
Mailing Address - City:CAYCE
Mailing Address - State:SC
Mailing Address - Zip Code:29033-3748
Mailing Address - Country:US
Mailing Address - Phone:317-828-4720
Mailing Address - Fax:
Practice Address - Street 1:1137 FORT CONGAREE TRL APT 2637
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-3748
Practice Address - Country:US
Practice Address - Phone:317-828-4720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer