Provider Demographics
NPI:1306012067
Name:GULF COAST AUDIOLOGY OF SOUTHWEST FLORIDA LLC
Entity type:Organization
Organization Name:GULF COAST AUDIOLOGY OF SOUTHWEST FLORIDA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUDIOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DRIANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DURAN
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:239-267-7888
Mailing Address - Street 1:8900 GLADIOLUS DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4487
Mailing Address - Country:US
Mailing Address - Phone:239-267-7888
Mailing Address - Fax:239-267-0409
Practice Address - Street 1:8900 GLADIOLUS DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4487
Practice Address - Country:US
Practice Address - Phone:239-267-7888
Practice Address - Fax:239-267-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1164261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600507100Medicaid
0140162OtherGHI
1548335813OtherTRICARE
S9326OtherBCBS
01088308OtherAMERIGROUP
0140162OtherGHI