Healthcare Provider Details

I. General information

NPI: 1992206155
Provider Name (Legal Business Name): KINMED, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 02/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19910 S TAMIAMI TRL STE C
ESTERO FL
33928-4140
US

IV. Provider business mailing address

19910 S TAMIAMI TRL STE C
ESTERO FL
33928-4140
US

V. Phone/Fax

Practice location:
  • Phone: 239-948-1222
  • Fax: 239-948-1220
Mailing address:
  • Phone: 239-948-1222
  • Fax: 239-948-1220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LYETTE BOUCHER
Title or Position: PRESIDENT
Credential: DC
Phone: 239-948-1222