MEDICARE: PRP CENTERS OF FLORIDA LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	ME0050622	FL

General Provider Information

NPI Number	:	1265882096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRP CENTERS OF FLORIDA LLC

Provider Business Mailing Address
First Line	:	1225 SUNBURY DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8738
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 SUNBURY DR
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8738
Country	:	US
Telephone Number	:	239-338-7074
Fax Number	:

Authorized Official
Title or Position	:	MD
Name	:	KENNEH BACKSTRAND
Credential	:
Telephone Number	:	239-338-7074

Provider Enumeration Date	:	06/13/2016
Last Update Date	:	06/13/2016

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