Basic Information
| Provider Information | |||||||||
| NPI: | 1659089399 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COATES | ||||||||
| FirstName: | KIRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10033 LUNETH DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809251468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105668823 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5526 N ACADEMY BLVD STE 109 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809183688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193015100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2022 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | CO | Y |
ID Information
| ID | Type | State | Issuer | Description | 1790211605 | 05 | CO | MEDICAID |