Provider Demographics
NPI:1801157839
Name:IMMOKALEE FAMILY DOCTOR'S CLINIC, LLC
Entity type:Organization
Organization Name:IMMOKALEE FAMILY DOCTOR'S CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:KEPPEL
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:239-657-2779
Mailing Address - Street 1:555 N 15TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2824
Mailing Address - Country:US
Mailing Address - Phone:239-657-2779
Mailing Address - Fax:239-657-3335
Practice Address - Street 1:555 N 15TH ST UNIT A
Practice Address - Street 2:
Practice Address - City:IMMOKALEE
Practice Address - State:FL
Practice Address - Zip Code:34142-2824
Practice Address - Country:US
Practice Address - Phone:239-657-2779
Practice Address - Fax:239-657-3335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-06
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42490208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113836500Medicaid
FL11132Medicare PIN
FLD52120Medicare UPIN