Healthcare Provider Details

I. General information

NPI: 1497425789
Provider Name (Legal Business Name): FAMILY HEALTH CENTERS OF SOUTHWEST FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 06/21/2022
Certification Date: 06/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 S MAIN ST
LABELLE FL
33935-4448
US

IV. Provider business mailing address

PO BOX 919771
ORLANDO FL
32891-0001
US

V. Phone/Fax

Practice location:
  • Phone: 863-675-0160
  • Fax: 863-675-1346
Mailing address:
  • Phone: 239-278-3600
  • Fax: 239-479-5122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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