Healthcare Provider Details

I. General information

NPI: 1124539226
Provider Name (Legal Business Name): PIEDMONT PLACE HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6706 N 9TH AVE STE B5
PENSACOLA FL
32504-7378
US

IV. Provider business mailing address

6706 N 9TH AVE STE B5
PENSACOLA FL
32504-7378
US

V. Phone/Fax

Practice location:
  • Phone: 850-816-0220
  • Fax: 850-270-6658
Mailing address:
  • Phone: 850-816-0220
  • Fax: 850-270-6658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH10096
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT12069
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA66580
License Number StateFL

VIII. Authorized Official

Name: DAVID ZIMMERMAN
Title or Position: PRESIDENT
Credential:
Phone: 850-816-0220