Healthcare Provider Details

I. General information

NPI: 1760293872
Provider Name (Legal Business Name): CHILD NEUROLOGY CENTER OF NORTHWEST FLORIDA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12815 US HIGHWAY 98 W STE 116
MIRAMAR BEACH FL
32550-3245
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: 850-932-1404
Mailing address:
  • Phone: 850-932-5055
  • Fax: 850-932-1404

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: JAMES BEN RENFROE
Title or Position: PRESIDENT
Credential: MD
Phone: 850-932-5055