=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548690936
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENSACOLA HOUSE CALLS,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2013
-----------------------------------------------------
Last Update Date | 11/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5040 YESTEROAKS CIR
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-377-5268
-----------------------------------------------------
Fax | 850-474-1892
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5040 YESTEROAKS CIR
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-4316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-377-5268
-----------------------------------------------------
Fax | 850-474-1892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. STEPHEN D. BAST
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 850-377-5268
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA1962
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------