Basic Information
Provider Information | |||||||||
NPI: | 1497020549 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ESCAMBIA COMMUNITY CLINICS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ECC URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2315 W JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 325057552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504364630 | ||||||||
FaxNumber: | 8504362095 | ||||||||
Practice Location | |||||||||
Address1: | 14 W JORDAN ST | ||||||||
Address2: | SUITE A | ||||||||
City: | PENSACOLA | ||||||||
State: | FL | ||||||||
PostalCode: | 32501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8504364630 | ||||||||
FaxNumber: | 8504362095 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2012 | ||||||||
LastUpdateDate: | 07/23/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SMILEY | ||||||||
AuthorizedOfficialFirstName: | CHANDRA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8504364630 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ESCAMBIA COMMUNITY CLINICS INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 692990728 | 05 | FL |   | MEDICAID |