Healthcare Provider Details

I. General information

NPI: 1417377813
Provider Name (Legal Business Name): FAMILY HEALTH CENTERS OF SOUTHWEST FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 DEL PRADO BLVD S
CAPE CORAL FL
33990-1710
US

IV. Provider business mailing address

PO BOX 919771
ORLANDO FL
32891-9771
US

V. Phone/Fax

Practice location:
  • Phone: 239-314-1616
  • Fax: 239-772-1613
Mailing address:
  • Phone: 239-278-3600
  • Fax: 239-278-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPH29774
License Number StateFL

VIII. Authorized Official

Name: FRANK MAZZEO JR.
Title or Position: PRESIDENT/CEO
Credential: DDS
Phone: 239-278-3600