Healthcare Provider Details

I. General information

NPI: 1942367057
Provider Name (Legal Business Name): NORTHWEST FLORIDA HEALTHCARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

IV. Provider business mailing address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

V. Phone/Fax

Practice location:
  • Phone: 850-638-1610
  • Fax: 850-638-5764
Mailing address:
  • Phone: 850-638-1610
  • Fax: 850-638-5764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number4005
License Number StateFL

VIII. Authorized Official

Name: GREGG J MOREAU
Title or Position: CFO & COO
Credential:
Phone: 850-415-8197