1063632040 NPI number — FARAH FAMILY HEALTH CENTER INC

Table of content: (NPI 1063632040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063632040 NPI number — FARAH FAMILY HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FARAH FAMILY HEALTH CENTER INC
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:
Provider Other Organization Name Type Code:
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:
1063632040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9267
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33902-9267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-334-3545
Provider Business Mailing Address Fax Number:
239-334-6085

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3049 CLEVELAND AVE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
FORT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33901-7049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-334-3545
Provider Business Practice Location Address Fax Number:
239-334-6085
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LARSEN
Authorized Official First Name:
GUY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
239-334-3545

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  ME0026178 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208600000X , with the licence number: ME0026178 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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