MEDICARE: KOALA HEALTH & WELLNESS CENTERS INC.

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	F004567	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0008ER	OTHER	TX	BCBS GROUP ID

General Provider Information

NPI Number	:	1073637260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOALA HEALTH & WELLNESS CENTERS INC.

Provider Business Mailing Address
First Line	:	4665 SW FWY
Second Line	:	#214
City	:	HOUSTON
State	:	TX
Zip	:	77027
Country	:	US
Telephone Number	:	713-652-9777
Fax Number	:	713-651-0584

Provider Business Practice Location Address
First Line	:	4665 SW FWY
Second Line	:	#214
City	:	HOUSTON
State	:	TX
Zip	:	77027
Country	:	US
Telephone Number	:	713-652-9777
Fax Number	:	713-651-0584

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	DR. EDWIN DEAN KIEKE
Credential	:	D.C.
Telephone Number	:	713-652-9777

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	10/15/2021

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