Provider Demographics
NPI:1326773045
Name:PROVIDENCE FAMILY LIFE CENTER CORPORATION
Entity Type:Organization
Organization Name:PROVIDENCE FAMILY LIFE CENTER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-720-7694
Mailing Address - Street 1:3049 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-7041
Mailing Address - Country:US
Mailing Address - Phone:239-676-3159
Mailing Address - Fax:888-519-9202
Practice Address - Street 1:3592 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8056
Practice Address - Country:US
Practice Address - Phone:239-676-3159
Practice Address - Fax:239-519-9202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty