Provider Demographics
NPI:1891949707
Name:KINETIC KIDS, INC.
Entity Type:Organization
Organization Name:KINETIC KIDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER & PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANI
Authorized Official - Middle Name:S
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MPT
Authorized Official - Phone:704-807-5699
Mailing Address - Street 1:9611 BROOKDALE DR
Mailing Address - Street 2:SUITE 100-122
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8719
Mailing Address - Country:US
Mailing Address - Phone:704-807-5699
Mailing Address - Fax:704-631-4574
Practice Address - Street 1:1016 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-4520
Practice Address - Country:US
Practice Address - Phone:704-807-5699
Practice Address - Fax:704-631-4574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251E00000X, 252Y00000X, 261QA3000X, 261QC1500X, 261QD1600X, 261QH0100X, 261QH0700X, 261QM0855X, 261QM1300X, 261QR0400X, 261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No251E00000XAgenciesHome HealthGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider Agency
No261QA3000XAmbulatory Health Care FacilitiesClinic/CenterAugmentative Communication
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7200262Medicaid