Provider Demographics
NPI:1861415770
Name:KIRBY, KENNETH W JR (DPT, CSCS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:KIRBY
Suffix:JR
Gender:M
Credentials:DPT, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:847 WAKE FOREST BUSINESS PARK
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6575
Mailing Address - Country:US
Mailing Address - Phone:919-542-9410
Mailing Address - Fax:919-542-2948
Practice Address - Street 1:847 WAKE FOREST BUSINESS PARK
Practice Address - Street 2:SUITE 202
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6575
Practice Address - Country:US
Practice Address - Phone:919-562-9410
Practice Address - Fax:919-542-2948
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10662225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC068EPOtherBCBS
NC89013RFMedicaid
NC7280958OtherAETNA
NC199858OtherMEDCOST
NC250132CMedicare PIN
NC250132Medicare PIN
NC250132AMedicare PIN
NC199858OtherMEDCOST