Provider Demographics
NPI:1477858751
Name:COMMUNITY MEDICAL CARE CENTER
Entity Type:Organization
Organization Name:COMMUNITY MEDICAL CARE CENTER
Other - Org Name:N/A
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-657-5800
Mailing Address - Street 1:214 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-3904
Mailing Address - Country:US
Mailing Address - Phone:239-657-5800
Mailing Address - Fax:239-657-9600
Practice Address - Street 1:214 S 1ST ST
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-3904
Practice Address - Country:US
Practice Address - Phone:239-657-5800
Practice Address - Fax:239-657-9600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-18
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN248261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI-51898Medicare UPIN