Provider Demographics
NPI:1700386810
Name:THE CHARLOTTE ATHLETE LLC
Entity Type:Organization
Organization Name:THE CHARLOTTE ATHLETE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:KENAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:215-380-3187
Mailing Address - Street 1:260 W BLAND ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-4104
Mailing Address - Country:US
Mailing Address - Phone:215-380-3187
Mailing Address - Fax:
Practice Address - Street 1:5046 OLD PINEVILLE RD STE 190
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-3035
Practice Address - Country:US
Practice Address - Phone:215-380-3187
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-15
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2000X
NCP16460261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation