1588171789 NPI number — NORTHWEST FLORIDA HEALTHCARE, INC.

Table of content: (NPI 1588171789)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588171789 NPI number — NORTHWEST FLORIDA HEALTHCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST FLORIDA HEALTHCARE, INC.
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:
6
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:
1588171789
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1360 BRICKYARD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHIPLEY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32428-6303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-638-1610
Provider Business Mailing Address Fax Number:
850-638-0622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5429 COLLEGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRACEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32440-1858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-263-0639
Provider Business Practice Location Address Fax Number:
850-263-6561
Provider Enumeration Date:
01/09/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MORGAN
Authorized Official First Name:
MARCEY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
850-415-8127

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100739300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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