Healthcare Provider Details

I. General information

NPI: 1427713130
Provider Name (Legal Business Name): NORTHWEST FLORIDA HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 6TH ST
MARIANNA FL
32446-1930
US

IV. Provider business mailing address

1360 BRICKYARD RD
CHIPLEY FL
32428-6303
US

V. Phone/Fax

Practice location:
  • Phone: 850-482-4655
  • Fax: 850-482-6694
Mailing address:
  • Phone: 850-638-1610
  • Fax: 850-638-0622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN LISENBY
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 850-415-8107