Basic Information
| Provider Information | |||||||||
| NPI: | 1417377813 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH CENTERS OF SOUTHWEST FLORIDA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 919771 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328919771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392783600 | ||||||||
| FaxNumber: | 2392783857 | ||||||||
| Practice Location | |||||||||
| Address1: | 316 DEL PRADO BLVD S | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339901710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2393141616 | ||||||||
| FaxNumber: | 2397721613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2014 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | MAZZEO | ||||||||
| AuthorizedOfficialFirstName: | FRANK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2392783600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0002X | PH29774 | FL | N | Suppliers | Pharmacy | Clinic Pharmacy | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 99409 | 01 | FL | BCBS | OTHER | 029570126 | 05 | FL | MEDICAID | 029570125 | 05 | FL | MEDICAID |