MEDICARE: KAIKOA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	12301	TX

General Provider Information

NPI Number	:	1023468485
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAIKOA LLC

Provider Business Mailing Address
First Line	:	4525 HERITAGE TRACE PKWY
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8908
Country	:	US
Telephone Number	:	817-431-5100
Fax Number	:	817-887-3008

Provider Business Practice Location Address
First Line	:	4525 HERITAGE TRACE PKWY
Second Line	:	SUITE 101
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8908
Country	:	US
Telephone Number	:	817-431-5100
Fax Number	:	817-887-3008

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JESSE JACOBS
Credential	:	D.C.
Telephone Number	:	214-636-6906

Provider Enumeration Date	:	06/16/2016
Last Update Date	:	06/16/2016

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Directions to “KAIKOA LLC ” Practice Location

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