Provider Demographics
NPI:1003198565
Name:ISLAND COAST PRIMARY CARE PROJECT, INC.
Entity Type:Organization
Organization Name:ISLAND COAST PRIMARY CARE PROJECT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-461-8375
Mailing Address - Street 1:4150 FORD STREET EXT STE 1B
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9498
Mailing Address - Country:US
Mailing Address - Phone:239-461-8375
Mailing Address - Fax:239-461-7639
Practice Address - Street 1:4150 FORD STREET EXT STE 1B
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-9498
Practice Address - Country:US
Practice Address - Phone:239-467-8375
Practice Address - Fax:239-461-7639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
No251B00000XAgenciesCase Management