1962854257 NPI number — FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962854257 NPI number — FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FLORIDA CANCER SPECIALISTS & RESEARCH INSTITUTE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FLORIDA CANCER SPECIALISTS P L
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962854257
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4371 VERONICA S SHOEMAKER BLVD
Provider Second Line Business Mailing Address:
ATTN CREDENTIALING
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33916-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-432-8500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 STATE ROAD 60 W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE WALES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33853-4118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-679-9000
Provider Business Practice Location Address Fax Number:
863-679-9005
Provider Enumeration Date:
07/11/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GORDAN
Authorized Official First Name:
LUCIO
Authorized Official Middle Name:
NAVARRO
Authorized Official Title or Position:
PRESIDENT/MANAGING PARTNER
Authorized Official Telephone Number:
239-274-8200

Provider Taxonomy Codes

  • Taxonomy code: 207RH0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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