Organization
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Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICHARD G HEADLEY (OWNER)
(239) 390-1077
Entity
Organization
Contact information
Practice address
25270 BERNWOOD DR, UNIT 5, BONITA SPRINGS, FL 34135-7897
(239) 390-1077
(239) 390-0444
Mailing address
25270 BERNWOOD DR, UNIT 5, BONITA SPRINGS, FL 34135-7897
(239) 390-1077
(239) 390-0444
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
1651
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
026048700
—
FL
01
—
R9401
BLUE CROSS BLUE SHIELD
FL
Enumeration date
05/31/2005
Last updated
06/07/2012
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