MEDICARE: FAMILY HEALTH CENTERS OF SOUTHWEST FLORIDA, 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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1417661893
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY HEALTH CENTERS OF SOUTHWEST FLORIDA, INC.

Provider Business Mailing Address
First Line	:	PO BOX 919771
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32891-9771
Country	:	US
Telephone Number	:	239-278-3600
Fax Number	:	239-479-5202

Provider Business Practice Location Address
First Line	:	2450 EDISON AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-5127
Country	:	US
Telephone Number	:	239-278-3600
Fax Number	:	239-479-5202

Authorized Official
Title or Position	:	CREDENTIALING ADMINISTRATOR
Name	:	KRYSTLE CAMERON
Credential	:
Telephone Number	:	239-344-2391

Provider Enumeration Date	:	01/10/2023
Last Update Date	:	01/10/2023

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