Provider Demographics
NPI:1275141558
Name:FLORIDA GULF COAST UNIVERISTY
Entity Type:Organization
Organization Name:FLORIDA GULF COAST UNIVERISTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. AD FOR HEALTH PERFORMANCE
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:NECOLE
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:LAT
Authorized Official - Phone:239-745-4299
Mailing Address - Street 1:10501 FGCU BLVD S
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33965-6502
Mailing Address - Country:US
Mailing Address - Phone:239-742-4299
Mailing Address - Fax:239-590-7398
Practice Address - Street 1:10501 FGCU BLVD S
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33965-6502
Practice Address - Country:US
Practice Address - Phone:239-742-4299
Practice Address - Fax:239-590-7398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-22
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME80216OtherSTATE LICENSE