MEDICARE: ELEVATE MEDICAL FORT MYERS, LLC

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	261QM1300X	Multi-Specialty Clinic/Center

General Provider Information

NPI Number	:	1306461447
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELEVATE MEDICAL FORT MYERS, LLC

Provider Business Mailing Address
First Line	:	1850 BOY SCOUT DR STE A102
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2127
Country	:	US
Telephone Number	:	662-501-0043
Fax Number	:	662-560-0161

Provider Business Practice Location Address
First Line	:	1850 BOY SCOUT DR STE A102
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33907-2127
Country	:	US
Telephone Number	:	870-919-6686
Fax Number	:	662-560-0161

Authorized Official
Title or Position	:	OWNER
Name	:	JEREMY MITCHELL
Credential	:	BSN
Telephone Number	:	870-919-6686

Provider Enumeration Date	:	06/15/2020
Last Update Date	:	06/15/2020

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