Healthcare Provider Details

I. General information

NPI: 1013587955
Provider Name (Legal Business Name): PEA RIDGE FAMILY CARE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5553 HIGHWAY 90
PACE FL
32571-1540
US

IV. Provider business mailing address

5500 N DAVIS HWY STE 2
PENSACOLA FL
32503-2063
US

V. Phone/Fax

Practice location:
  • Phone: 850-995-8811
  • Fax: 850-995-8810
Mailing address:
  • Phone: 850-475-0867
  • Fax: 850-475-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PURUSHOTTAM K. GARG
Title or Position: OWNER
Credential: MD
Phone: 850-995-8811