MEDICARE: PROTECTED HARBOR 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	10001700	FL

General Provider Information

NPI Number	:	1437665627
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROTECTED HARBOR INC

Provider Business Mailing Address
First Line	:	4561 CAMINO REAL WAY
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1026
Country	:	US
Telephone Number	:	239-278-0200
Fax Number	:

Provider Business Practice Location Address
First Line	:	4561 CAMINO REAL WAY
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33966-1026
Country	:	US
Telephone Number	:	239-278-0200
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CHARLES PERRY DUNCAN
Credential	:
Telephone Number	:	239-278-0200

Provider Enumeration Date	:	12/26/2017
Last Update Date	:	12/26/2017

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