Provider Demographics
NPI:1093386732
Name:KICOS WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:KICOS WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHAR
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KICOS
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:330-880-4888
Mailing Address - Street 1:2823 AARONWOOD AVE NE STE A
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-2371
Mailing Address - Country:US
Mailing Address - Phone:330-880-4888
Mailing Address - Fax:
Practice Address - Street 1:2823 AARONWOOD AVE NE STE A
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44646-2371
Practice Address - Country:US
Practice Address - Phone:330-880-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-04
Last Update Date:2021-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0376111Medicaid