Provider Demographics
NPI:1306202221
Name:ELY, LAWRENCE
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:ELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 MARAVILLA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7135
Mailing Address - Country:US
Mailing Address - Phone:239-334-0222
Mailing Address - Fax:239-334-0244
Practice Address - Street 1:1940 MARAVILLA AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7135
Practice Address - Country:US
Practice Address - Phone:239-334-0222
Practice Address - Fax:239-334-0244
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-07
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management