Provider Demographics
NPI:1700104528
Name:EXECUTIVE MANAGEMENT FOR ADULT CARE LLC
Entity Type:Organization
Organization Name:EXECUTIVE MANAGEMENT FOR ADULT CARE LLC
Other - Org Name:EMAC
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCIA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FOWLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:239-338-8069
Mailing Address - Street 1:15660 SAN CARLOS BLVD
Mailing Address - Street 2:UNIT # 294
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-2526
Mailing Address - Country:US
Mailing Address - Phone:239-338-8069
Mailing Address - Fax:
Practice Address - Street 1:15660 SAN CARLOS BLVD
Practice Address - Street 2:UNIT # 294
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-2526
Practice Address - Country:US
Practice Address - Phone:239-338-8069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-05
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7238261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center