Basic Information
| Provider Information | |||||||||
| NPI: | 1588944334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALHOUN-LIBERTY HOSPITAL ASSOCIATION INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CALHOUN-LIBERTY PRIMARY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 20370 NE BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324241045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506745411 | ||||||||
| FaxNumber: | 8506743550 | ||||||||
| Practice Location | |||||||||
| Address1: | 20370 NE BURNS AVE | ||||||||
| Address2: | |||||||||
| City: | BLOUNTSTOWN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324241045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506745411 | ||||||||
| FaxNumber: | 8506743550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 11/22/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TAYLOR | ||||||||
| AuthorizedOfficialFirstName: | DARA | ||||||||
| AuthorizedOfficialMiddleName: | NICOLE | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSINESS OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8506745411 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | HCC680 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.