1225084833 NPI number — NORTH OKALOOSA HEALTH CARE ASSOCIATES LLC

Table of content: (NPI 1225084833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225084833 NPI number — NORTH OKALOOSA HEALTH CARE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTH OKALOOSA HEALTH CARE ASSOCIATES LLC
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:
SHOAL CREEK REHABILITATION CENTER
Provider Other Organization Name Type Code:
3
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:
1225084833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 HOSPITAL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32539-7355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-689-3146
Provider Business Mailing Address Fax Number:
850-689-2286

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 HOSPITAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32539-7355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-689-3146
Provider Business Practice Location Address Fax Number:
850-689-2286
Provider Enumeration Date:
05/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALTZ
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
850-689-3146

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  SNF130471012 , 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: 025237900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com