Healthcare Provider Details

I. General information

NPI: 1013908201
Provider Name (Legal Business Name): HEALTHMARK OF WALTON RURAL HEALTH CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4415 US HIGHWAY 331 S
DEFUNIAK SPRINGS FL
32435-6307
US

IV. Provider business mailing address

4415 US HIGHWAY 331 S
DEFUNIAK SPRINGS FL
32435-6307
US

V. Phone/Fax

Practice location:
  • Phone: 850-951-4640
  • Fax: 850-892-7079
Mailing address:
  • Phone: 850-951-4640
  • Fax: 850-892-7079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA SHIRLEY HOLLEY
Title or Position: COO
Credential:
Phone: 850-951-4507