Provider Demographics
NPI:1811342397
Name:KIMBERLY REGENESIS
Entity type:Organization
Organization Name:KIMBERLY REGENESIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MOURACADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-313-0296
Mailing Address - Street 1:14661 DOUBLE EAGLE COURT
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912
Mailing Address - Country:US
Mailing Address - Phone:239-313-0296
Mailing Address - Fax:239-939-1070
Practice Address - Street 1:8695 COLLEGE PARKWAY
Practice Address - Street 2:SUITE 2080
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919
Practice Address - Country:US
Practice Address - Phone:239-313-0296
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility