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General NPI Number Information
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NPI Number | 1245481597
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Entity Type | Organization
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Legal Business Name | SOUTHWEST FLORIDA FACIAL PLASTIC SURGERY ASSOCIATES INC.
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Dates
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Enumeration Date | 10/06/2008
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Last Update Date | 05/20/2014
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Provider Practice Location Address
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Address Line | 9407 CYPRESS LAKE DR STE A
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City | FORT MYERS
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State | FL
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Zip | 33919-0910
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Country | US
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Telephone | 239-473-7390
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Fax |
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Provider Business Mailing Address
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Address Line | 9407 CYPRESS LAKE DR STE A
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City | FORT MYERS
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State | FL
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Zip | 33919-0910
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Country | US
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Telephone | 239-473-7390
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. STEPHEN A PRENDIVILLE
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Credential | M.D.
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Telephone | 239-437-3900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME81906
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License Number State | FL
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