Healthcare Provider Details

I. General information

NPI: 1588032270
Provider Name (Legal Business Name): SUWANNEE BEND SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2015
Last Update Date: 09/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N MAIN ST STE 2
CHIEFLAND FL
32626-0870
US

IV. Provider business mailing address

220 N MAIN ST STE 2
CHIEFLAND FL
32626-0870
US

V. Phone/Fax

Practice location:
  • Phone: 352-490-7500
  • Fax:
Mailing address:
  • Phone: 352-490-7500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 13604
License Number StateFL

VIII. Authorized Official

Name: FRANK MARTIN
Title or Position: MANAGER
Credential:
Phone: 352-333-3995