Healthcare Provider Details

I. General information

NPI: 1336856731
Provider Name (Legal Business Name): FLORIDA REGIONAL INTENSIVIST SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2022
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 W 23RD ST
PANAMA CITY FL
32405-4507
US

IV. Provider business mailing address

PO BOX 80325
PHILADELPHIA PA
19101-1325
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-8341
  • Fax:
Mailing address:
  • Phone: 973-251-1132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: OFFICER
Credential:
Phone: 973-251-1132