=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275711889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KID SPIRIT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2008
-----------------------------------------------------
Last Update Date | 02/06/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9350 CAMELOT DR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33919-7980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-344-7217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9350 CAMELOT DR
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33919-7980
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-344-7217
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PARTNER
-----------------------------------------------------
Name | JAESEN PETRETTA
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 239-839-3408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number | OT10199
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------