Healthcare Provider Details

I. General information

NPI: 1205989183
Provider Name (Legal Business Name): PEDIATRIC CENTERS OF LEE CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4048 EVANS AVE STE 209
FT MYERS FL
33901
US

IV. Provider business mailing address

4048 EVANS AVE STE 209
FT MYERS FL
33901
US

V. Phone/Fax

Practice location:
  • Phone: 239-278-9983
  • Fax: 239-278-9985
Mailing address:
  • Phone: 239-278-9983
  • Fax: 239-278-9985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. CARLOS L MORALES
Title or Position: OFFICE MANAGER
Credential:
Phone: 239-278-9983