MEDICARE: KICOS CHIROPRACTIC, 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	2396	NC

General Provider Information

NPI Number	:	1609132356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KICOS CHIROPRACTIC, INC.

Provider Business Mailing Address
First Line	:	19810 W CATAWBA AVE
Second Line	:	SUITE B
City	:	CORNELIUS
State	:	NC
Zip	:	28031-4056
Country	:	US
Telephone Number	:	704-895-3203
Fax Number	:	704-895-3204

Provider Business Practice Location Address
First Line	:	19810 W CATAWBA AVE
Second Line	:	SUITE B
City	:	CORNELIUS
State	:	NC
Zip	:	28031-4056
Country	:	US
Telephone Number	:	704-895-3203
Fax Number	:	704-895-3204

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JOHN J KICOS
Credential	:	D.C.
Telephone Number	:	704-895-3203

Provider Enumeration Date	:	04/06/2012
Last Update Date	:	04/06/2012

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