Healthcare Provider Details

I. General information

NPI: 1922099928
Provider Name (Legal Business Name): PHC-FT WALTON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 11/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 L B J SR DR
FT WALTON BEACH FL
32547-1163
US

IV. Provider business mailing address

909 GARDENGATE CIR
PENSACOLA FL
32504
US

V. Phone/Fax

Practice location:
  • Phone: 850-863-2066
  • Fax: 850-863-9006
Mailing address:
  • Phone: 850-479-1012
  • Fax: 850-479-1013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberFL14605
License Number StateFL

VIII. Authorized Official

Name: MR. WILLIAM AROL HUDSON
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 850-863-2066