Provider Demographics
NPI:1003358284
Name:KALIOPE GOUTIS
Entity Type:Organization
Organization Name:KALIOPE GOUTIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:KALIOPE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-946-3963
Mailing Address - Street 1:8323E MIDDLE LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-2024
Mailing Address - Country:US
Mailing Address - Phone:727-946-3963
Mailing Address - Fax:
Practice Address - Street 1:8323E MIDDLE LEWIS AVE
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13603-2024
Practice Address - Country:US
Practice Address - Phone:727-946-3963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-05
Last Update Date:2016-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3178921251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03934241Medicaid