Basic Information
| Provider Information | |||||||||
| NPI: | 1205340098 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAIROS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 715 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419564943 | ||||||||
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| Practice Location | |||||||||
| Address1: | 711 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414745579 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | STARK | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SKILLS COACH | ||||||||
| AuthorizedOfficialTelephone: | 5412262880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor |
No ID Information.