Healthcare Provider Details

I. General information

NPI: 1275141558
Provider Name (Legal Business Name): FLORIDA GULF COAST UNIVERISTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 09/29/2020
Certification Date: 09/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10501 FGCU BLVD S
FORT MYERS FL
33965-6502
US

IV. Provider business mailing address

10501 FGCU BLVD S
FORT MYERS FL
33965-6502
US

V. Phone/Fax

Practice location:
  • Phone: 239-742-4299
  • Fax: 239-590-7398
Mailing address:
  • Phone: 239-742-4299
  • Fax: 239-590-7398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name: PAULA NECOLE NEAL
Title or Position: ASST. AD FOR HEALTH PERFORMANCE
Credential: LAT
Phone: 239-745-4299