Provider Demographics
NPI:1730405796
Name:PROHEALTH PRIMARY CARE LLC
Entity type:Organization
Organization Name:PROHEALTH PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:COUGHLAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA C
Authorized Official - Phone:239-949-5585
Mailing Address - Street 1:1656 EXECUTIVE DR
Mailing Address - Street 2:#302
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110
Mailing Address - Country:US
Mailing Address - Phone:239-514-4799
Mailing Address - Fax:239-514-3621
Practice Address - Street 1:1656 MEDICAL BLVD
Practice Address - Street 2:#302
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110
Practice Address - Country:US
Practice Address - Phone:239-514-4799
Practice Address - Fax:239-514-3621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102717363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2690XMedicare PIN