Healthcare Provider Details

I. General information

NPI: 1437384518
Provider Name (Legal Business Name): PHOENIXCO.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 MIRACLE STRIP PKWY SW STE 13
FORT WALTON BEACH FL
32548-5258
US

IV. Provider business mailing address

36132 EMERALD COAST PKWY
DESTIN FL
32541-5776
US

V. Phone/Fax

Practice location:
  • Phone: 850-244-2900
  • Fax: 850-796-2700
Mailing address:
  • Phone: 850-424-3914
  • Fax: 850-424-3931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ADAM POLLOCK
Title or Position: CEO
Credential:
Phone: 337-315-9456