1326556200 NPI number — SOUTHERN PRACTITIONER

Table of content: (NPI 1326556200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326556200 NPI number — SOUTHERN PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN PRACTITIONER
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:
1326556200
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
904 N 75TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32506-3820
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-434-0077
Provider Business Mailing Address Fax Number:
850-434-0220

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 W MAXWELL ST
Provider Second Line Business Practice Location Address:
STE 148
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32501-1717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-434-0077
Provider Business Practice Location Address Fax Number:
850-434-0220
Provider Enumeration Date:
01/13/2018

Additional Information

Authorized Official

Authorized Official Last Name:
PRINCE
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-434-0077

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  9167682 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 111684900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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