Provider Demographics
NPI:1669010369
Name:LEE MEMORIAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:LEE MEMORIAL HEALTH SYSTEM
Other - Org Name:LCH-PEDS CAPE CORAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEBERGALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-424-1446
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-424-1449
Mailing Address - Fax:239-424-1423
Practice Address - Street 1:650 DEL PRADO BLVD S STE 107
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-5629
Practice Address - Country:US
Practice Address - Phone:239-343-9888
Practice Address - Fax:239-424-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)