Healthcare Provider Details

I. General information

NPI: 1780264572
Provider Name (Legal Business Name): KIMMIE'S RECOVERY ZONE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2021
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 JEFFERSON AVE
FORT MYERS FL
33901-8438
US

IV. Provider business mailing address

9090 GLADIOLUS PRESERVE CIR
FORT MYERS FL
33908-9705
US

V. Phone/Fax

Practice location:
  • Phone: 239-872-0071
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JULIUS A KINKLE SR.
Title or Position: CHAIRMAN
Credential: CPRS
Phone: 239-872-0071