Healthcare Provider Details

I. General information

NPI: 1740078062
Provider Name (Legal Business Name): SANTA ROSA HB MEDICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4250 WOODBINE RD
PACE FL
32571-8703
US

IV. Provider business mailing address

PO BOX 680060
FRANKLIN TN
37068-0060
US

V. Phone/Fax

Practice location:
  • Phone: 877-848-1457
  • Fax: 659-235-6176
Mailing address:
  • Phone: 615-465-7000
  • Fax: 659-235-6176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: WENDI KEETON
Title or Position: SR. DIRECTOR, OPERATIONS
Credential:
Phone: 615-628-6507