Provider Demographics
NPI:1629388319
Name:EXCELLENCE MEDICAL CENTERS,LLC
Entity Type:Organization
Organization Name:EXCELLENCE MEDICAL CENTERS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-540-0800
Mailing Address - Street 1:4304 DEL PRADO BLVD S
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33904-7169
Mailing Address - Country:US
Mailing Address - Phone:239-540-0800
Mailing Address - Fax:239-540-0806
Practice Address - Street 1:4304 DEL PRADO BLVD S
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7169
Practice Address - Country:US
Practice Address - Phone:239-540-0800
Practice Address - Fax:239-540-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME94225208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273771000Medicaid
FL29322OtherBC BS
FL103645Medicare UPIN