Provider Demographics
NPI:1457788960
Name:FLORENCE KIMBO M.D., LLC
Entity Type:Organization
Organization Name:FLORENCE KIMBO M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:V
Authorized Official - Last Name:KIMBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-234-8746
Mailing Address - Street 1:18660 BAGLEY RD BLDG 1
Mailing Address - Street 2:SUITE 404
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44130-3483
Mailing Address - Country:US
Mailing Address - Phone:440-234-8746
Mailing Address - Fax:
Practice Address - Street 1:18660 BAGLEY RD BLDG 1
Practice Address - Street 2:SUITE 404
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3483
Practice Address - Country:US
Practice Address - Phone:440-234-8746
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-28
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10003791041C0700X
OHCOA12811164W00000X
OH350941832084P0800X
OH350877762084P0804X
OH350857382084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0092217Medicaid
OH0092217Medicaid