Provider Demographics
NPI:1194321067
Name:KICKS LLC
Entity type:Organization
Organization Name:KICKS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-348-0011
Mailing Address - Street 1:143 S 29TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1903
Mailing Address - Country:US
Mailing Address - Phone:740-348-0011
Mailing Address - Fax:
Practice Address - Street 1:143 S 29TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1903
Practice Address - Country:US
Practice Address - Phone:740-348-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
4504343OtherDODD