Provider Demographics
NPI:1275711889
Name:KID SPIRIT, INC.
Entity Type:Organization
Organization Name:KID SPIRIT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JAESEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:239-839-3408
Mailing Address - Street 1:9350 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-7980
Mailing Address - Country:US
Mailing Address - Phone:239-344-7217
Mailing Address - Fax:
Practice Address - Street 1:9350 CAMELOT DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-7980
Practice Address - Country:US
Practice Address - Phone:239-344-7217
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT10199261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty