Basic Information
| Provider Information | |||||||||
| NPI: | 1023687993 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH OKALOOSA CLINIC CORP | ||||||||
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| OtherOrganizationName: | NORTH OKALOOSA CLINIC CORP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154657211 | ||||||||
| FaxNumber: | 6156286877 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 REDSTONE AVE W STE 410 | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325366457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503062188 | ||||||||
| FaxNumber: | 8503988470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2021 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIR PROV ENROLLMENT & ONBOARDING | ||||||||
| AuthorizedOfficialTelephone: | 6154653334 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 273693415 | 05 | FL | MEDICAID |