Basic Information
| Provider Information | |||||||||
| NPI: | 1194919993 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLIER HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHS-FSU PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583707 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1441 HERITAGE BLVD | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2007 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2396583707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 683955012 | 05 | FL | MEDICAID |