Provider Demographics
NPI:1235271669
Name:PEDIATRIC CENTERS OF LEE COUNTY
Entity Type:Organization
Organization Name:PEDIATRIC CENTERS OF LEE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-278-9983
Mailing Address - Street 1:222 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6018
Mailing Address - Country:US
Mailing Address - Phone:239-368-5437
Mailing Address - Fax:239-369-0880
Practice Address - Street 1:222 PLAZA DR
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6018
Practice Address - Country:US
Practice Address - Phone:239-368-5437
Practice Address - Fax:239-369-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255363501Medicaid