1457446387 NPI number — NICEVILLE PRIMARY CARE BLUEWATER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457446387 NPI number — NICEVILLE PRIMARY CARE BLUEWATER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NICEVILLE PRIMARY CARE BLUEWATER
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:
1457446387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4400 E HIGHWAY 20
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
NICEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32578-8779
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-897-3678
Provider Business Mailing Address Fax Number:
850-897-3708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 E HIGHWAY 20
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
NICEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32578-8779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-897-3678
Provider Business Practice Location Address Fax Number:
850-897-3708
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PICKLER
Authorized Official First Name:
MICKEY
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
850-523-2117

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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