Provider Demographics
NPI:1881289387
Name:FAMILY UNIVERSAL MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:FAMILY UNIVERSAL MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OTNIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC
Authorized Official - Phone:305-833-4707
Mailing Address - Street 1:4531 DELEON ST STE 207
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1280
Mailing Address - Country:US
Mailing Address - Phone:239-220-5115
Mailing Address - Fax:239-201-2601
Practice Address - Street 1:4531 DELEON ST STE 207
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1280
Practice Address - Country:US
Practice Address - Phone:239-220-5115
Practice Address - Fax:239-201-2601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty