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General NPI Number Information
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NPI Number | 1629412515
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Entity Type | Organization
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Legal Business Name | CLUB2,LLC
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Dates
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Enumeration Date | 04/22/2013
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Last Update Date | 04/22/2013
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Provider Practice Location Address
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Address Line | 1230 CRANE COVE BLVD
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City | GULF BREEZE
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State | FL
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Zip | 32563-3191
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Country | US
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Telephone | 850-934-6659
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Fax |
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Provider Business Mailing Address
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Address Line | 1175 MARY KATE DR
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City | GULF BREEZE
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State | FL
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Zip | 32563-5542
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Country | US
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Telephone | 850-934-6659
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. PAUL ROEBUCK HENNING
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Credential | M.D
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Telephone | 850-696-9556
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0002X
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Taxonomy Name | Emergency Care Clinic/Center
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License Number | ME93462
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License Number State | FL
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