Basic Information
| Provider Information | |||||||||
| NPI: | 1528564911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLIER HEALTH SERVICE, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY CARE NORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1454 MADISON AVE W | ||||||||
| Address2: | |||||||||
| City: | IMMOKALEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341422200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583137 | ||||||||
| FaxNumber: | 2396583051 | ||||||||
| Practice Location | |||||||||
| Address1: | 1265 CREEKSIDE PKWY STE 206 | ||||||||
| Address2: | |||||||||
| City: | NAPLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341081954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396583710 | ||||||||
| FaxNumber: | 2395912154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2018 | ||||||||
| LastUpdateDate: | 04/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | MIKE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2396583158 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COLLIER HEALTH SERVICE, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.