MEDICARE: KIM ROTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN9365090	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	163W00000X	OTHER	FL	163W00000X

General Provider Information

NPI Number	:	1518353390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM ROTH

Provider Business Mailing Address
First Line	:	3285 CYPRESS LEGENDS CIR APT 934
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-5537
Country	:	US
Telephone Number	:	301-787-7783
Fax Number	:

Provider Business Practice Location Address
First Line	:	3285 CYPRESS LEGENDS CIR APT 934
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33905-5537
Country	:	US
Telephone Number	:	301-787-7783
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/08/2015
Last Update Date	:	04/08/2015

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Directions to “ KIM ROTH ” Practice Location

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