Healthcare Provider Details

I. General information

NPI: 1760883276
Provider Name (Legal Business Name): MOORINGS PARK HEALTHY LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 MOORINGS PARK DR
NAPLES FL
34105-2122
US

IV. Provider business mailing address

132 MOORINGS PARK DR
NAPLES FL
34105-2122
US

V. Phone/Fax

Practice location:
  • Phone: 239-430-6387
  • Fax: 239-430-6365
Mailing address:
  • Phone: 239-430-6387
  • Fax: 239-430-6365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateFL

VIII. Authorized Official

Name: MARY MORTON
Title or Position: CORPORATE COMPLIANCE OFFICER
Credential:
Phone: 239-643-9168