Provider Demographics
NPI:1134774805
Name:KAOF SPORTS THERAPEUTIC GUIDANCE GROUP LLC
Entity type:Organization
Organization Name:KAOF SPORTS THERAPEUTIC GUIDANCE GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KENYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-526-6665
Mailing Address - Street 1:2000 FOREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29715-6432
Mailing Address - Country:US
Mailing Address - Phone:803-526-6665
Mailing Address - Fax:
Practice Address - Street 1:2000 FOREST RIDGE DR
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-6432
Practice Address - Country:US
Practice Address - Phone:803-526-6665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)