Provider Demographics
NPI:1912190174
Name:S.T.A.C.K. PHYSICAL THERAPY & CORRECTIVE EXERCISE, INCORPORATED
Entity Type:Organization
Organization Name:S.T.A.C.K. PHYSICAL THERAPY & CORRECTIVE EXERCISE, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:STACK
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT,CSCS
Authorized Official - Phone:1800-362-0903
Mailing Address - Street 1:1640 EVA MAE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-4443
Mailing Address - Country:US
Mailing Address - Phone:800-362-0903
Mailing Address - Fax:866-434-5096
Practice Address - Street 1:1640 EVA MAE DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-4443
Practice Address - Country:US
Practice Address - Phone:800-362-0903
Practice Address - Fax:866-434-5096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8899261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy