Healthcare Provider Details

I. General information

NPI: 1861052896
Provider Name (Legal Business Name): PREMIER ADULT AND CHILDRENS SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5238 MASON CORBIN CT STE 101
FORT MYERS FL
33907-7738
US

IV. Provider business mailing address

5238 MASON CORBIN CT STE 101
FORT MYERS FL
33907-7738
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-9700
  • Fax: 239-936-9707
Mailing address:
  • Phone: 239-936-9700
  • Fax: 239-936-9707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENETHA D MORAN
Title or Position: OFFICER/AUTHORIZED OFFICIAL
Credential:
Phone: 972-763-3893