Healthcare Provider Details

I. General information

NPI: 1811342397
Provider Name (Legal Business Name): KIMBERLY REGENESIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2016
Last Update Date: 07/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8695 COLLEGE PARKWAY SUITE 2080
FT MYERS FL
33919
US

IV. Provider business mailing address

14661 DOUBLE EAGLE COURT
FT MYERS FL
33912
US

V. Phone/Fax

Practice location:
  • Phone: 239-313-0296
  • Fax:
Mailing address:
  • Phone: 239-313-0296
  • Fax: 239-939-1070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. THOMAS MICHAEL MOURACADE
Title or Position: PRINCIPAL/OWNER
Credential:
Phone: 239-313-0296