Provider Demographics
NPI:1326177858
Name:KOALA SPORTS MEDICINE CENTERS LP
Entity Type:Organization
Organization Name:KOALA SPORTS MEDICINE CENTERS LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:KIEKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:713-652-9777
Mailing Address - Street 1:PO BOX 890389
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77289-0389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 S CONGRESS AVE
Practice Address - Street 2:B11
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-8707
Practice Address - Country:US
Practice Address - Phone:512-326-5333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0022KUOtherBCBS GROUP ID #