=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487724969
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA DEPARTMENT OF HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2006
-----------------------------------------------------
Last Update Date | 10/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4979 HEALTHY WAY
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-7993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-526-2412
-----------------------------------------------------
Fax | 850-718-0383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4979 HEALTHY WAY PO BOX 310
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-7993
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-526-2412
-----------------------------------------------------
Fax | 850-718-0383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING ADMINISTRATOR
-----------------------------------------------------
Name | MRS. SUSANNAH CULBREATH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-526-2412
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0901X
-----------------------------------------------------
Taxonomy Name | Public Health & General Preventive Medicine Physician
-----------------------------------------------------
License Number | ME86600
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251K00000X
-----------------------------------------------------
Taxonomy Name | Public Health or Welfare Agency
-----------------------------------------------------
License Number | ME86600
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------