MEDICARE: FORT MYERS FL ICF OPCO 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	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942956909
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT MYERS FL ICF OPCO LLC

Provider Business Mailing Address
First Line	:	980 SYLVAN AVE
Second Line	:
City	:	ENGLEWOOD CLIFFS
State	:	NJ
Zip	:	07632-3301
Country	:	US
Telephone Number	:	201-928-7800
Fax Number	:

Provider Business Practice Location Address
First Line	:	2975 GARDEN ST
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33917-1883
Country	:	US
Telephone Number	:	239-995-5833
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	BATYA GORELICK
Credential	:
Telephone Number	:	239-995-5833

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	02/28/2022

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