Provider Demographics
NPI:1609132356
Name:KICOS CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:KICOS CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KICOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-895-3203
Mailing Address - Street 1:19810 W CATAWBA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4056
Mailing Address - Country:US
Mailing Address - Phone:704-895-3203
Mailing Address - Fax:704-895-3204
Practice Address - Street 1:19810 W CATAWBA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-4056
Practice Address - Country:US
Practice Address - Phone:704-895-3203
Practice Address - Fax:704-895-3204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-06
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2396111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2450911AMedicare PIN