Healthcare Provider Details

I. General information

NPI: 1982224259
Provider Name (Legal Business Name): EXCALIBUR TELEMEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2020
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 WATERFORD LN
GULF BREEZE FL
32561-4872
US

IV. Provider business mailing address

405 WATERFORD LN
GULF BREEZE FL
32561-4872
US

V. Phone/Fax

Practice location:
  • Phone: 850-982-9384
  • Fax: 850-934-0711
Mailing address:
  • Phone: 850-982-9384
  • Fax: 850-934-0711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KIM LANDRY
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 850-982-9384