1700803624 NPI number — PRIMARY CARE CENTER OF LYNN HAVEN

Table of content: (NPI 1700803624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700803624 NPI number — PRIMARY CARE CENTER OF LYNN HAVEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRIMARY CARE CENTER OF LYNN HAVEN
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700803624
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/26/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1199
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LYNN HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32444-1199
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-265-3686
Provider Business Mailing Address Fax Number:
850-271-5665

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 FLORIDA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LYNN HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32444-2335
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-265-3686
Provider Business Practice Location Address Fax Number:
850-271-5665
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KHATTAK
Authorized Official First Name:
ASIM
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-265-3686

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1700803624 . This is a "NPI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 276096700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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