Provider Demographics
NPI:1346994969
Name:KINAM, LLC
Entity Type:Organization
Organization Name:KINAM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WAIVER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:FISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-850-2497
Mailing Address - Street 1:3908 SEIXAS PL
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-4500
Mailing Address - Country:US
Mailing Address - Phone:813-850-2497
Mailing Address - Fax:
Practice Address - Street 1:3908 SEIXAS PL
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-4500
Practice Address - Country:US
Practice Address - Phone:813-850-2497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691176596Medicaid