MEDICARE: PHC-FT WALTON INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	FL14605	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922099928
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHC-FT WALTON INC

Provider Business Mailing Address
First Line	:	909 GARDENGATE CIR
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32504
Country	:	US
Telephone Number	:	850-479-1012
Fax Number	:	850-479-1013

Provider Business Practice Location Address
First Line	:	1 L B J SR DR
Second Line	:
City	:	FT WALTON BEACH
State	:	FL
Zip	:	32547-1163
Country	:	US
Telephone Number	:	850-863-2066
Fax Number	:	850-863-9006

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. WILLIAM AROL HUDSON
Credential	:	MBA
Telephone Number	:	850-863-2066

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	11/12/2009

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