=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124288428
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIAN COLBERT LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2008
-----------------------------------------------------
Last Update Date | 06/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5117 CASTELLO DR STE 2
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34103-1925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-218-2310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18313 USEPPA ROAD
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33967-5436
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-218-2310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number | MA35406
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------