Healthcare Provider Details

I. General information

NPI: 1770818601
Provider Name (Legal Business Name): INSTITUTE OF MEDICAL EXCELLENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2009
Last Update Date: 10/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MICROSPINE WAY
DEFUNIAK SPRINGS FL
32435
US

IV. Provider business mailing address

PO BOX 1262
DEFUNIAK SPRINGS FL
32435-1262
US

V. Phone/Fax

Practice location:
  • Phone: 850-892-4248
  • Fax:
Mailing address:
  • Phone: 850-892-4248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2112
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP2539562
License Number StateFL

VIII. Authorized Official

Name: DR. KINLEY WAYNE HOWARD
Title or Position: PRESIDENT
Credential: DPM, CRNA
Phone: 850-892-4248