Healthcare Provider Details

I. General information

NPI: 1699770545
Provider Name (Legal Business Name): BIG BEND OPERATIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N BYRON BUTLER PKWY
PERRY FL
32347-2315
US

IV. Provider business mailing address

555 N BYRON BUTLER PKWY
PERRY FL
32347-2315
US

V. Phone/Fax

Practice location:
  • Phone: 850-584-2778
  • Fax: 850-584-2790
Mailing address:
  • Phone: 850-584-2778
  • Fax: 850-584-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number1076
License Number StateFL

VIII. Authorized Official

Name: CHARLES SCOTT KEELER
Title or Position: MANAGER EMPLOYEE / CEO
Credential:
Phone: 850-584-2778