Healthcare Provider Details

I. General information

NPI: 1376644666
Provider Name (Legal Business Name): KOALA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 W IRVING BLVD SUITE 750
IRVING TX
75061-6871
US

IV. Provider business mailing address

1901 W IRVING BLVD STE 750
IRVING TX
75061-6823
US

V. Phone/Fax

Practice location:
  • Phone: 972-821-0137
  • Fax:
Mailing address:
  • Phone: 972-821-0137
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number332B00000X
License Number StateTX

VIII. Authorized Official

Name: MRS. LINDA J CLAGUE
Title or Position: OWNER
Credential:
Phone: 972-262-0891