Provider Demographics
NPI:1659864411
Name:COLLIER HEALTH SERVICES, INC
Entity Type:Organization
Organization Name:COLLIER HEALTH SERVICES, INC
Other - Org Name:FAMILY CARE NORTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CRREDENTIAING
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-658-3707
Mailing Address - Street 1:1454 MADISON AVE W
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2200
Mailing Address - Country:US
Mailing Address - Phone:239-658-3000
Mailing Address - Fax:
Practice Address - Street 1:1265 CREEKSIDE PKWY STE 206
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34108-1954
Practice Address - Country:US
Practice Address - Phone:239-658-3710
Practice Address - Fax:239-591-2154
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLLIER HEALTH SERVICES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-07
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)