Provider Demographics
NPI:1548263114
Name:FLORIDA DEPARTMENT OF HEALTH
Entity type:Organization
Organization Name:FLORIDA DEPARTMENT OF HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OMC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-643-2415
Mailing Address - Street 1:12832 NW CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-0489
Mailing Address - Country:US
Mailing Address - Phone:850-643-2292
Mailing Address - Fax:850-643-2306
Practice Address - Street 1:10971 NW SPRING STREET
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-0489
Practice Address - Country:US
Practice Address - Phone:850-643-2292
Practice Address - Fax:850-643-2306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL027949891Medicaid
FL027949803Medicaid
FL027949805Medicaid
FL027949808Medicaid
FL027949802Medicaid
FL027949800Medicaid
FL027949807Medicaid
10-1820OtherMEDICARE FQHC
FL027949804Medicaid
FL027949830Medicaid
FL72156OtherBCBS
FL027949800Medicaid