1467409953 NPI number — HEARTLAND OF FORT MYERS FL, LLC

Table of content: (NPI 1467409953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467409953 NPI number — HEARTLAND OF FORT MYERS FL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEARTLAND OF FORT MYERS FL, 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:
Provider Other Organization Name Type Code:
6
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:
1467409953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
333 N SUMMIT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43604-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-252-5500
Provider Business Mailing Address Fax Number:
877-385-9446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 MATTHEW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT MYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-1700
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-275-6067
Provider Business Practice Location Address Fax Number:
239-275-9716
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
419-252-5734

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF12060961 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 032532500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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