Healthcare Provider Details

I. General information

NPI: 1972594729
Provider Name (Legal Business Name): PHC-BLOUNTSTOWN INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2005
Last Update Date: 06/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17884 NE CROZIER ST
BLOUNTSTOWN FL
32424-1050
US

IV. Provider business mailing address

909 GARDEN GATE CIR
PENSACOLA FL
32504-8629
US

V. Phone/Fax

Practice location:
  • Phone: 850-674-5464
  • Fax: 850-674-9384
Mailing address:
  • Phone: 850-682-5322
  • Fax: 850-689-2510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF12870961
License Number StateFL

VIII. Authorized Official

Name: MRS. CATHERINE A ATES
Title or Position: PRESIDENT, CHIEF OPERATING OFFICER
Credential: R.N.
Phone: 850-682-5322