Provider Demographics
NPI:1073707741
Name:COLLIER HEALTH SERVICES INC
Entity Type:Organization
Organization Name:COLLIER HEALTH SERVICES INC
Other - Org Name:HEALTHCARE NETWORK OF SW FL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-658-3707
Mailing Address - Street 1:1454 MADISON AVE W
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2200
Mailing Address - Country:US
Mailing Address - Phone:239-658-3000
Mailing Address - Fax:
Practice Address - Street 1:1749 HERITAGE TRL # 801
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34112-7591
Practice Address - Country:US
Practice Address - Phone:239-658-3000
Practice Address - Fax:239-774-2317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL683955011Medicaid