Healthcare Provider Details

I. General information

NPI: 1821412016
Provider Name (Legal Business Name): FAMILY HEALTH CENTERS OF SOUTHWEST FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19701 S TAMIAMI TRL
FORT MYERS FL
33908-4818
US

IV. Provider business mailing address

PO BOX 919771
ORLANDO FL
32891-9771
US

V. Phone/Fax

Practice location:
  • Phone: 239-314-1600
  • Fax: 239-425-6402
Mailing address:
  • Phone: 239-278-3600
  • Fax: 239-226-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License NumberPH28479
License Number StateFL

VIII. Authorized Official

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