Provider Demographics
NPI:1114296209
Name:MOORINGS PARK HEALTHY LIVING, INC
Entity Type:Organization
Organization Name:MOORINGS PARK HEALTHY LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-643-9168
Mailing Address - Street 1:120 MOORINGS PARK DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34105-2122
Mailing Address - Country:US
Mailing Address - Phone:239-430-6387
Mailing Address - Fax:239-430-6365
Practice Address - Street 1:120 MOORINGS PARK DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34105-2122
Practice Address - Country:US
Practice Address - Phone:239-430-6387
Practice Address - Fax:239-430-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFX839AOtherPTAN