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General NPI Number Information
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NPI Number | 1407301757
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Entity Type | Organization
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Legal Business Name | GULF COAST ADDICTION MEDICINE
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Dates
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Enumeration Date | 08/16/2016
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 277 FOREST PARK CIR
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City | PANAMA CITY
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State | FL
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Zip | 32405-4920
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Country | US
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Telephone | 850-522-1516
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Fax | 850-522-1518
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Provider Business Mailing Address
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Address Line | 277 FOREST PARK CIR
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City | PANAMA CITY
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State | FL
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Zip | 32405-4920
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Country | US
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Telephone | 850-522-1516
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Fax | 850-522-1518
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNIFER BURKETT
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Credential |
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Telephone | 850-522-1516
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0301
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License Number State | FL
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