Healthcare Provider Details

I. General information

NPI: 1205535572
Provider Name (Legal Business Name): HEALTHY COMMUNITY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 SE 47TH TER STE B
CAPE CORAL FL
33904-8593
US

IV. Provider business mailing address

506 SE 47TH TER STE B
CAPE CORAL FL
33904-8593
US

V. Phone/Fax

Practice location:
  • Phone: 305-989-1837
  • Fax:
Mailing address:
  • Phone: 239-673-9825
  • Fax: 239-257-2326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFF GARCIA
Title or Position: PRESIDENT
Credential:
Phone: 239-673-9825