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General NPI Number Information
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NPI Number | 1578618104
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Entity Type | Organization
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Legal Business Name | ALL SEASONS ALLERGY AND ASTHMA CENTER, P.A.
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Dates
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Enumeration Date | 01/24/2007
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Last Update Date | 10/03/2017
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Provider Practice Location Address
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Address Line | 362 BEAL PKWY NW STE 105
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-3926
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Country | US
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Telephone | 850-862-3020
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Fax | 850-862-1363
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Provider Business Mailing Address
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Address Line | 362 BEAL PKWY NW STE 105
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-3926
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Country | US
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Telephone | 850-862-3020
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Fax | 850-862-1363
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. JUSTIN CLARK
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Credential | D.O.
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Telephone | 850-862-3020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207K00000X
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Taxonomy Name | Allergy & Immunology Physician
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License Number | OS9224
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License Number State | FL
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