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General NPI Number Information
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NPI Number | 1225634462
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Entity Type | Organization
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Legal Business Name | BEACHSIDE PEDIATRIC ASSOCIATES, P.A.
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Dates
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Enumeration Date | 12/10/2020
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Last Update Date | 01/21/2021
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Provider Practice Location Address
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Address Line | 490 HIGHWAY 85 N
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City | NICEVILLE
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State | FL
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Zip | 32578-1010
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Country | US
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Telephone | 850-419-2691
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Fax | 850-353-2142
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Provider Business Mailing Address
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Address Line | 1590 RUCKEL DR
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City | NICEVILLE
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State | FL
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Zip | 32578-1603
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Country | US
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Telephone | 850-621-5058
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Fax |
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Authorized Official
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Title or Position | PROJECT MANAGER
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Name | CLAYTON COVELL LANCASTER
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Credential |
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Telephone | 850-758-8331
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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