Healthcare Provider Details

I. General information

NPI: 1750954566
Provider Name (Legal Business Name): GULFSHORE PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 SW HEALTH PKWY STE 100
NAPLES FL
34109-0473
US

IV. Provider business mailing address

1890 SW HEALTH PKWY STE 100
NAPLES FL
34109-0473
US

V. Phone/Fax

Practice location:
  • Phone: 239-207-8844
  • Fax: 207-216-8902
Mailing address:
  • Phone: 239-207-8844
  • Fax: 207-216-8902

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 Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE L BECKER
Title or Position: OWNER, PRACTICING PHYSICIAN
Credential: MD
Phone: 239-207-8844