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General NPI Number Information
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NPI Number | 1922099928
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Entity Type | Organization
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Legal Business Name | PHC-FT WALTON INC
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Dates
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Enumeration Date | 10/31/2005
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Last Update Date | 11/12/2009
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Provider Practice Location Address
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Address Line | 1 L B J SR DR
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City | FT WALTON BEACH
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State | FL
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Zip | 32547-1163
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Country | US
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Telephone | 850-863-2066
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Fax | 850-863-9006
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Provider Business Mailing Address
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Address Line | 909 GARDENGATE CIR
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City | PENSACOLA
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State | FL
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Zip | 32504
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Country | US
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Telephone | 850-479-1012
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Fax | 850-479-1013
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. WILLIAM AROL HUDSON
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Credential | MBA
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Telephone | 850-863-2066
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | FL14605
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License Number State | FL
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