=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760981260
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PANAMA CITY SPRINGS & RECOVERY CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2018
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1212 W 19TH ST
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-4104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-567-6164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3562 FOUR OAKS BLVD
-----------------------------------------------------
City | TALLAHASSEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32311-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-567-6164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. WARREN PEARSON
-----------------------------------------------------
Credential | JD
-----------------------------------------------------
Telephone | 850-567-6164
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0802X
-----------------------------------------------------
Taxonomy Name | Addiction Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------