MEDICARE: ISLAND COAST PRIMARY CARE PROJECT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251B00000X	Case Management Agency
2	3140N1450X	Pediatric Skilled Nursing Facility

General Provider Information

NPI Number	:	1003198565
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ISLAND COAST PRIMARY CARE PROJECT, INC.

Provider Business Mailing Address
First Line	:	4150 FORD STREET EXT STE 1B
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-9498
Country	:	US
Telephone Number	:	239-461-8375
Fax Number	:	239-461-7639

Provider Business Practice Location Address
First Line	:	4150 FORD STREET EXT STE 1B
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916-9498
Country	:	US
Telephone Number	:	239-467-8375
Fax Number	:	239-461-7639

Authorized Official
Title or Position	:	PROGRAM ADMINISTRATOR
Name	:	CATHY JONES
Credential	:
Telephone Number	:	239-461-8375

Provider Enumeration Date	:	09/12/2011
Last Update Date	:	09/12/2011

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