MEDICARE: KOALA SPORTS MEDICINE CENTERS LP

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0022KU	OTHER	TX	BCBS GROUP ID #

General Provider Information

NPI Number	:	1326177858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOALA SPORTS MEDICINE CENTERS LP

Provider Business Mailing Address
First Line	:	PO BOX 890389
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77289-0389
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 S CONGRESS AVE
Second Line	:	B11
City	:	AUSTIN
State	:	TX
Zip	:	78704-8707
Country	:	US
Telephone Number	:	512-326-5333
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ED KIEKE
Credential	:	D.C.
Telephone Number	:	713-652-9777

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	08/22/2020

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