Healthcare Provider Details

I. General information

NPI: 1386781342
Provider Name (Legal Business Name): PENSACOLA PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 U.S. HIGHWAY 29 SOUTH
CANTONMENT FL
32533
US

IV. Provider business mailing address

2360 U.S. HIGHWAY 29 SOUTH
CANTONMENT FL
32533
US

V. Phone/Fax

Practice location:
  • Phone: 850-968-2083
  • Fax: 850-968-6024
Mailing address:
  • Phone: 850-968-2083
  • Fax: 850-968-6024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MICKEY PICKLER
Title or Position: VICE PRESIDENT
Credential:
Phone: 850-523-2117