=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003467960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GALENUS GROUP, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/23/2019
-----------------------------------------------------
Last Update Date | 09/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1530 LEE BLVD STE 1400
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-4887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-368-7310
-----------------------------------------------------
Fax | 239-368-7312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1530 LEE BLVD STE 1400
-----------------------------------------------------
City | LEHIGH ACRES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33936-4887
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-368-7310
-----------------------------------------------------
Fax | 239-368-7312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | DR. EDGARDO CASTILLO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 239-368-7310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------