Healthcare Provider Details

I. General information

NPI: 1063485118
Provider Name (Legal Business Name): FSL-PANAMA CITY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 JENKS AVE
PANAMA CITY FL
32405-4530
US

IV. Provider business mailing address

100 2ND AVE S
ST PETERSBURG FL
33701-4360
US

V. Phone/Fax

Practice location:
  • Phone: 850-763-0446
  • Fax: 850-763-7787
Mailing address:
  • Phone: 727-820-8409
  • Fax: 727-822-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberSNF1366095
License Number StateFL

VIII. Authorized Official

Name: DOREEN MARTIN
Title or Position: VP OF AR
Credential:
Phone: 727-820-8409