MEDICARE: PRINCE PROPERTIES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician

General Provider Information

NPI Number	:	1326529355
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCE PROPERTIES

Provider Business Mailing Address
First Line	:	128 EGLIN PKWY SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5519
Country	:	US
Telephone Number	:	850-374-1203
Fax Number	:

Provider Business Practice Location Address
First Line	:	128 EGLIN PKWY SE
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32548-5519
Country	:	US
Telephone Number	:	850-374-1203
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LESLEY J PRINCE
Credential	:
Telephone Number	:	601-832-1465

Provider Enumeration Date	:	08/27/2018
Last Update Date	:	08/27/2018

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