Provider Demographics
NPI:1295065266
Name:KICO
Entity type:Organization
Organization Name:KICO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:EDITH
Authorized Official - Last Name:WEDDINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-896-1331
Mailing Address - Street 1:4931 MESA BONITA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78218-2756
Mailing Address - Country:US
Mailing Address - Phone:210-896-1331
Mailing Address - Fax:210-896-1331
Practice Address - Street 1:4931 MESA BONITA
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78218-2756
Practice Address - Country:US
Practice Address - Phone:210-896-1331
Practice Address - Fax:210-896-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities