Healthcare Provider Details

I. General information

NPI: 1053392233
Provider Name (Legal Business Name): CHILD NEUROLOGY CENTER OF NORTHWEST FLORIDA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GULF BREEZE PKWY SUITE 300
GULF BREEZE FL
32561-4495
US

IV. Provider business mailing address

PO BOX 280
GULF BREEZE FL
32562-0280
US

V. Phone/Fax

Practice location:
  • Phone: 850-932-5055
  • Fax: 850-932-1401
Mailing address:
  • Phone: 850-932-5055
  • Fax: 850-932-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JAMES BEN RENFROE
Title or Position: OWNER
Credential: M.D.
Phone: 850-932-5055