Healthcare Provider Details

I. General information

NPI: 1942968524
Provider Name (Legal Business Name): BEACON HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1656 MEDICAL BLVD STE 301
NAPLES FL
34110-1423
US

IV. Provider business mailing address

1656 MEDICAL BLVD STE 301
NAPLES FL
34110-1423
US

V. Phone/Fax

Practice location:
  • Phone: 239-593-6204
  • Fax: 239-799-2131
Mailing address:
  • Phone: 239-799-7057
  • Fax: 239-799-2131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MOLLY HEINRICH
Title or Position: MANAGER
Credential: PA-C
Phone: 239-799-7057