Provider Demographics
NPI:1104644418
Name:KIWI HEALTH, LLC
Entity type:Organization
Organization Name:KIWI HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:570-709-3599
Mailing Address - Street 1:20 N ORANGE AVE STE 1100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-4605
Mailing Address - Country:US
Mailing Address - Phone:407-565-9597
Mailing Address - Fax:407-550-6458
Practice Address - Street 1:20 N ORANGE AVE STE 1100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-4605
Practice Address - Country:US
Practice Address - Phone:407-565-9597
Practice Address - Fax:407-550-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center