Organization
KIN MED, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. LYETTE ROSE BOUCHER (PRESIDENT)
(239) 948-1222
Entity
Organization
Contact information
Practice address
19910 S TAMIAMI TRAIL STE C, ESTERO, FL 33928
(239) 948-1222
(239) 948-1221
Mailing address
19910 S. TAMIAMI TRAIL STE C, ESTERO, FL 33928
(239) 948-1222
(239) 948-1221
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
CH11148
—
208D00000X
General Practice Physician
Primary
CH11313
FL
363A00000X
Physician Assistant
P.A.9104809
FL
Other
Enumeration date
03/01/2018
Last updated
03/01/2018
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