=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275141558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA GULF COAST UNIVERISTY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2020
-----------------------------------------------------
Last Update Date | 09/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10501 FGCU BLVD S
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33965-6502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-742-4299
-----------------------------------------------------
Fax | 239-590-7398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10501 FGCU BLVD S
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33965-6502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-742-4299
-----------------------------------------------------
Fax | 239-590-7398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASST. AD FOR HEALTH PERFORMANCE
-----------------------------------------------------
Name | PAULA NECOLE NEAL
-----------------------------------------------------
Credential | LAT
-----------------------------------------------------
Telephone | 239-745-4299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------