Healthcare Provider Details

I. General information

NPI: 1568107746
Provider Name (Legal Business Name): KIDZ KORNER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2022
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4565 COMMERCIAL DR STE 105
NICEVILLE FL
32578-8856
US

IV. Provider business mailing address

220 EGLIN PKWY SE
FORT WALTON BEACH FL
32548-5899
US

V. Phone/Fax

Practice location:
  • Phone: 850-353-2415
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE HORIN
Title or Position: OWNER
Credential:
Phone: 850-200-4348