=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417263997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EHW PROFESSIONAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2010
-----------------------------------------------------
Last Update Date | 08/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 W 23RD ST SUITE N 5
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-7610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-390-2203
-----------------------------------------------------
Fax | 850-248-2225
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2208 PENTLAND RD
-----------------------------------------------------
City | LYNN HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32444-5359
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-390-2203
-----------------------------------------------------
Fax | 850-248-2225
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | MR. ROGER WAYNE HOLLEGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 229-522-0535
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------