Healthcare Provider Details

I. General information

NPI: 1528654399
Provider Name (Legal Business Name): KACI L KIOUS MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACI L ORTON

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W TOWNLINE ST
CRESTON IA
50801-1054
US

IV. Provider business mailing address

3262 MAPLE AVE
LORIMOR IA
50149-8054
US

V. Phone/Fax

Practice location:
  • Phone: 641-782-7091
  • Fax:
Mailing address:
  • Phone: 515-313-7498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number00249
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: