Healthcare Provider Details

I. General information

NPI: 1912545955
Provider Name (Legal Business Name): RURAL PRIMARY CARE SOUTH-WALTON, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5551 US HIGHWAY 98 SUITE 2
SANTA ROSA BEACH FL
32459
US

IV. Provider business mailing address

5551 US HIGHWAY 98 SUITE 2
SANTA ROSA BEACH FL
32459
US

V. Phone/Fax

Practice location:
  • Phone: 850-420-5420
  • Fax: 850-244-8011
Mailing address:
  • Phone: 850-420-5420
  • Fax: 850-244-8011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA PATTON
Title or Position: PRACTICE MANAGER
Credential: RN
Phone: 850-420-5420