Healthcare Provider Details

I. General information

NPI: 1275172942
Provider Name (Legal Business Name): PCCM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2019
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3021 AIRPORT PULLING RD N STE 103
NAPLES FL
34105-3077
US

IV. Provider business mailing address

3021 AIRPORT PULLING RD N STE 103
NAPLES FL
34105-3077
US

V. Phone/Fax

Practice location:
  • Phone: 239-208-0381
  • Fax: 305-721-1545
Mailing address:
  • Phone: 239-208-0381
  • Fax: 305-721-1545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH BOOKMAN
Title or Position: PHYSICIAN
Credential: MD
Phone: 239-208-0381