MEDICARE: PROVIDENCE FAMILY LIFE CENTER CORPORATION

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	:	1326773045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE FAMILY LIFE CENTER CORPORATION

Provider Business Mailing Address
First Line	:	3049 CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-7041
Country	:	US
Telephone Number	:	239-676-3159
Fax Number	:	888-519-9202

Provider Business Practice Location Address
First Line	:	3592 BROADWAY STE 100
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8056
Country	:	US
Telephone Number	:	239-676-3159
Fax Number	:	239-519-9202

Authorized Official
Title or Position	:	BILLING SPECIALIST
Name	:	LAURA KOHLER
Credential	:
Telephone Number	:	813-720-7694

Provider Enumeration Date	:	07/18/2022
Last Update Date	:	07/18/2022

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