Provider Demographics
NPI:1992206155
Name:KINMED, P.A.
Entity Type:Organization
Organization Name:KINMED, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LYETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-948-1222
Mailing Address - Street 1:19910 S TAMIAMI TRL STE C
Mailing Address - Street 2:
Mailing Address - City:ESTERO
Mailing Address - State:FL
Mailing Address - Zip Code:33928-4140
Mailing Address - Country:US
Mailing Address - Phone:239-948-1222
Mailing Address - Fax:239-948-1220
Practice Address - Street 1:19910 S TAMIAMI TRL STE C
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-4140
Practice Address - Country:US
Practice Address - Phone:239-948-1222
Practice Address - Fax:239-948-1220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-23
Last Update Date:2018-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL111N00000X, 207LP2900X, 363A00000X
208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty