=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730790551
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SACRED HEART HEALTH SYSTEM, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2020
-----------------------------------------------------
Last Update Date | 05/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1890 SUMMIT BLVD
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-494-9001
-----------------------------------------------------
Fax | 850-473-2759
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4205 BELFORT RD STE 4015
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-3623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-450-6004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR ENROLLMENT
-----------------------------------------------------
Name | JEAN VALLIER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-450-6005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------