=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093077661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHILDREN'S VOLUNTEER HEALTH NETWORK INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2012
-----------------------------------------------------
Last Update Date | 06/11/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 78 LYNN DRIVE
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-622-3200
-----------------------------------------------------
Fax | 850-622-4700
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 2142
-----------------------------------------------------
City | SANTA ROSA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-622-3200
-----------------------------------------------------
Fax | 850-622-4700
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ZACH BILLINGSLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-622-3200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN18266
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------