Healthcare Provider Details

I. General information

NPI: 1215973870
Provider Name (Legal Business Name): FLORIDA DEPARTMENT OF HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 NOBLES FERRY RD PO DRAWER 6030
LIVE OAK FL
32064-2800
US

IV. Provider business mailing address

PO DRAWER 6030 915 NOBLES FERRY ROAD
LIVE OAK FL
32064-2800
US

V. Phone/Fax

Practice location:
  • Phone: 386-362-2708
  • Fax: 386-362-6301
Mailing address:
  • Phone: 386-362-2708
  • Fax: 386-362-6301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. PAMELA BLACKMON
Title or Position: ADMINISTRATOR
Credential: RN, BSN, MPH
Phone: 386-362-2708