Healthcare Provider Details

I. General information

NPI: 1699093971
Provider Name (Legal Business Name): MED PLUS OF NWF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 05/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 PAGE BACON RD SUITE 14
MARY ESTHER FL
32569-1610
US

IV. Provider business mailing address

323 PAGE BACON RD SUITE 14
MARY ESTHER FL
32569-1610
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6331
  • Fax: 850-226-6332
Mailing address:
  • Phone: 850-226-6331
  • Fax: 850-226-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: THEARON L SHIPMAN JR.
Title or Position: OWNER
Credential:
Phone: 850-240-0093