Provider Demographics
NPI:1386264026
Name:KODIAK CORPORATION
Entity type:Organization
Organization Name:KODIAK CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:NEW
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:303-915-9848
Mailing Address - Street 1:PO BOX 932
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:CO
Mailing Address - Zip Code:80530-0932
Mailing Address - Country:US
Mailing Address - Phone:303-915-9848
Mailing Address - Fax:720-738-0045
Practice Address - Street 1:451 OAK ST STE 207
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:CO
Practice Address - Zip Code:80530-7015
Practice Address - Country:US
Practice Address - Phone:720-738-0044
Practice Address - Fax:720-738-0045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-23
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care